The Disordered Couple [2 ed.] 1138578592, 9781138578593

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THE DISORDERED COUPLE 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. Len Sperry, M.D., Ph.D., is Professor of Mental Health Counseling and Director of Clinical Training at Florida Atlantic University and Clinical Professor of Psychiatry at the Medical College of Wisconsin, U.S.A. He is an early pioneer in psychotherapy outcome research, a leader in the treatment of personality disorders and disordered couples, and an originator of spiritually oriented psychotherapy. Among his 1000+ publications are six on psychopathology and eight on families and couples. Katherine Helm, Ph.D., is Professor of Psychology and Director of Graduate Programs in Counseling at Lewis University, Romeoville, IL, U.S.A., and a psychologist and supervisor of clinical training at a university counseling center. She has authored several publications about multicultural issues in mental health, couples and sexuality issues, and pedagogy in multicultural courses. Katherine has also appeared in training videos for counselors and therapists. Jon Carlson, Psy.D., Ed.D., was, until his death, Distinguished Professor at Adler University in Chicago, U.S.A. He authored 62 books and produced 300 instructional videos used to train the next generation of practitioners. He has received lifetime achievement awards from professional associations including the American Psychological Association, the American Counseling Association, and the North American Society of Adlerian Psychology.

“As couple therapy inevitably leaves the confines of private practice and becomes more and more incorporated into integrated primary care practices, this is the manual for the future. This is the book that will support core training in the helping professions. Couples counselors and marital therapists—in private practice or in agencies—social workers; couple/marital psychologists; psychiatrists and psychiatric nurses; pastoral counselors: get ready. These are the couples we will be serving for the next 25 years.” —from the Foreword by James Robert Bitter, Ed.D., Professor of Counseling and Human Development, East Tennessee State University, U.S.A.

THE DISORDERED COUPLE Second Edition

Edited by Len Sperry, Katherine Helm, and Jon Carlson

Second edition published 2019 by Routledge 52 Vanderbilt Avenue, New York, NY 10017 and by Routledge 2 Park Square, Milton Park, Abingdon, Oxon, OX14 4RN Routledge is an imprint of the Taylor & Francis Group, an informa business © 2019 Len Sperry, Katherine Helm, and Jon Carlson The right of the Len Sperry, Katherine Helm, and Jon Carlson to be identified as the authors of the editorial material, and of the authors for their individual chapters, has been asserted in accordance with sections 77 and 78 of the Copyright, Designs and Patents Act 1988. All rights reserved. No part of this book may be reprinted or reproduced or utilised in any form or by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying and recording, or in any information storage or retrieval system, without permission in writing from the publishers. Trademark notice: Product or corporate names may be trademarks or registered trademarks, and are used only for identification and explanation without intent to infringe. First edition published by Routledge, 1998 Library of Congress Cataloging-in-Publication Data Names: Sperry, Len, author. | Helm, Katherine (Katherine M.) author, editor. | Carlson, Jon, author, editor. Title: The disordered couple / Len Sperry, M.D., Ph.D., Katherine Helm, Ph.D. and Jon Carlson, Ed.D., Psy.D. Description: 2nd edition. | New York, NY : Routledge, 2019. | Includes ­bibliographical references and index. Identifiers: LCCN 2018054329 (print) | LCCN 2018059931 (ebook) | ISBN 9781351264044 (Master) | ISBN 9781351264037 (Adobe) | ISBN 9781351264013 (MobiPocket) | ISBN 9781351264020 (ePub) | ISBN 9781138578586 (hbk) | ISBN 9781138578593 (pbk) | ISBN 9781351264044 (ebk) Subjects: LCSH: Marital psychotherapy. | Mentally ill—Family relationships. Classification: LCC RC488.5 (ebook) | LCC RC488.5.D59 2019 (print) | DDC 616.89/1562—dc23 LC record available at https://lccn.loc.gov/2018054329 ISBN: 978-1-138-57858-6 (hbk) ISBN: 978-1-138-57859-3 (pbk) ISBN: 978-1-351-26404-4 (ebk) Typeset in Minion by Apex CoVantage, LLC

Dedication About four years ago, Jon Carlson and I (LS) began talking about revising the first edition of The Disordered Couple, which was published in 1998. Because of new and more complex challenges facing couples and their therapists, it was clear to us that that the scope of the revision needed to be broadened considerably. Jon and I were both enthused about the prospect of a new and expanded edition. We also decided that additional editorial help was needed, especially since Jon had begun undergoing a series of medical and surgical procedures. It was fortuitous that Katherine Helm, Ph.D., accepted the invitation to join us as a co-editor. The untimely passing of Dr. Carlson in early 2017 was difficult for us. Nevertheless, we persisted in completing the project that Jon was convinced was so important. Accordingly, Katherine and I want to dedicate this book in honor of our beloved friend and colleague, Jon D. Carlson, Ed.D., Psy.D. Jon was a significant friend, mentor, teacher, and author. When he asked me (KH) to work with he and Len on this project, I was honored to take part in such an important book. Even when Jon became ill, he was still highly invested in this book and what he thought an updated edition could contribute to the field. He was passionate in his dedication to the fields of psychology and counseling and was always seeking creative ways to teach practitioners and students how to help others in distress—especially couples. We miss you, Jon, and know that you would be happy with the completion of this book.

CONTENTS

Acknowledgments List of Editors and Contributors Foreword—James Robert Bitter

Introduction: The Changing Landscape of Couple Therapy Today and Tomorrow

x xi xiv

1

KATHERINE HELM AND LEN SPERRY

PART I

Treating Disordered Couples Today   1

Issues and Treatment Considerations in Couple Therapy Today

7 9

KATHERINE HELM

  2

Social Media and the Impact of Technology on Couples and Their Disorders

28

KIMBERLY DURIS

  3

Assessment, Diagnosis, and Case Conceptualization With Couples LEN SPERRY

42

viii Contents

PART II

Disordered Couples Today

63

  4

65

The Depressed and Bipolar Couple CHANTE’ D. DELOACH

  5

The Psychotic Couple

80

MICHAEL P. MANIACCI AND LEN SPERRY

  6

The Anxious Couple

104

KATIE L. SPRINGFIELD AND ROSA M. MACKLIN-HINKLE

  7

The Traumatized Couple

119

EMILY PETKUS

  8

The Borderline Couple

136

GEORGE STOUPAS

  9

The Narcissistic Couple

153

JAMES MORRIS III

10 The Histrionic–Obsessive Couple

170

LEN SPERRY AND MICHAEL P. MANIACCI

11 The Eating Disordered Couple

193

SOFIE AZMY

12 The Sexually Disordered Couple

207

SHANNON B. DERMER AND MOLLI E. MERCER

13 The Alcohol and Drug Addicted Couple

222

MICHAEL R. LLOYD AND ELLEN THURSBY

14 The Sexually Addicted Couple

238

EMILY PETKUS AND LISA BROWN

15 The Distracted Couple

254

LARRY MAUCIERI

16 The Domestic Violence Couple LISA BROWN

271

Contents  ix

PART III

Developmental Issues Impacting Couples

287

17 The Sandwich Generation: Stage of Life Issues in Couples

289

KEN OLIVER

18 Religious and Spiritual Problems in Couples

305

STEVEN J. SANDAGE, CHANCE A. BELL, SARAH H. MOON, AND ELIZABETH G. RUFFING

PART IV

Treating Disordered Couples: Retrospective and Prospective

323

19 The Disordered Couple: Past, Present, and Future

325

LEN SPERRY AND KATHERINE HELM

Index

329

ACKNOWLEDGMENTS

Len Sperry: I would be remiss if I did not acknowledge my mentor and cherished colleague and friend, Richard Cox, M.D., Ph.D. Richard trained and supervised me in the practice of couples and family therapy first as a postdoctoral intern at the Marriage and Family Center in La Jolla, California and then in co-teaching graduate courses and weekend seminars to couples and family therapists. I also wish to express my heartfelt appreciation to Dr. James Robert Bitter for his gracious Foreword and to Katherine Helm, my co-editor, for all her efforts in bringing this book to fruition. Katherine Helm: I would like to acknowledge two very talented graduate assistants at Lewis University, Kiersten Tinkoff and Erin Burns, for their quality work on this important book. I would also like to thank my co-editor, Len Sperry, for his wisdom, guidance, ideas, and hard work. Finally, I would like to thank my husband, Anton Lewis, for his patience, understanding, and support throughout this project.

EDITORS AND CONTRIBUTORS

Editors Len Sperry, M.D., Ph.D.,  is Professor of Mental Health Counseling and Director of Clinical Training at Florida Atlantic University and Clinical Professor of Psychiatry at the Medical College of Wisconsin. He is an early pioneer in psychotherapy outcome research, a leader in the treatment of personality disorders, and an originator of spiritually oriented psychotherapy. Among his 1000+ publications are six books on psychopathology and eight on families and couples. Katherine Helm, Ph.D., is Professor of Psychology and Director of Graduate Programs in Counseling at Lewis University, Romeoville, IL, and a psychologist and the supervisor of clinical training at a university counseling center. She has authored several publications about multicultural issues in mental health, couples and sexuality issues, and pedagogy in multicultural courses. She has also appeared training videos for counselors and therapists. Jon Carlson, Ed.D., Psy.D., was, until his death, Distinguished Professor at Adler University in Chicago, the author of 62 books, and the producer of 300 instructional videos used to train the next generation of practitioners. He has received lifetime achievement awards from several professional associations, including the American Psychological Association, the American Counseling Association, and the North American Society of Adlerian Psychology.

xii  Editors and Contributors

Contributors Sofie Azmy, Psy.D., HSPP, M.B.A., is Assistant Professor in the Division of Psychology and Counseling at Governors State University. Chance A. Bell, Ph.D., is affiliated with the Albert and Jessie Danielsen Institute, Boston University. Lisa Brown, LCPC, is Clinical Coordinator and Adjunct Faculty in the Psychology Department at Lewis University. She is a doctoral candidate at Governors State University in the Counselor Education and Supervision program. Chante’ D. DeLoach, Psy.D., is Professor of Clinical and Community Psychology at Santa Monica College. Through her Los Angeles-based private practice, she provides holistic and strengths-based individual, couples, and family counseling to people from diverse populations. Shannon B. Dermer, Ph.D., is Interim Dean of the College of Education at Governors State University. Kimberly Duris, Ed.D., LCPC, CADC, is Assistant Professor in the Master of Arts in Clinical Mental Health Counseling program at Lewis University. Rosa M. Macklin-Hinkle, Psy.D., is a licensed clinical psychologist in Houston, Texas currently working with senior citizens in long-term care settings. Michael R. Lloyd, Ph.D., LCSW, CADC, is Assistant Professor of Social Work at Lewis University. Michael P. Maniacci, Ph.D., is a clinical psychologist in private psychotherapy practice and is a consultant. Larry Maucieri, Ph.D., ABPP-CN, is a board-certified clinical neuropsychologist and associate professor at Governors State University. Molli E. Mercer is Assistant Professor of Counseling at Florida Gulf Coast University. Sarah H. Moon, Psy.D.,  is affiliated with the Albert and Jessie Danielsen Institute, Boston University. James Morris III, Ed.D., LCPC, is Assistant Professor of Clinical Mental Health Counseling and Psychology at Lewis University.

Editors and Contributors  xiii

Ken Oliver, Ph.D., LPC, serves as Division Chair for the School of Education, Professor of Counseling, and Graduate Counseling Program Director at Quincy University in Quincy, Illinois. Emily Petkus, LCPC, is a doctoral candidate at Governors State University in the Counselor Education and Supervision program. Elizabeth G. Ruffing, MTS, is affiliated with the Department of Psychological and Brain Sciences and Albert and Jessie Danielsen Institute, Boston University. Steven J. Sandage, Ph.D., is affiliated with the Jessie Danielsen Institute, Boston University, and MF Norwegian School of Theology. Katie L. Springfield, Psy.D., is a graduate of Adler University and completed her post-doctoral fellowship at Genesis Therapy Center. She currently resides outside of Richmond, Virginia. George Stoupas, Ph.D., LMHC, is Associate Professor of Psychology and Human Services at Palm Beach State College. Ellen Thursby, Ph.D., LICSW, is Assistant Professor of Social Work at Lewis University.

FOREWORD

The Disordered Couple: Moving Forward It is December of 2017, and I am in Anaheim, California, at the Evolution of Psychotherapy Conference, walking out of a clinical demonstration by a master of individual therapy, a therapist I  have admired for 30  years. His room has many hundreds of people there to see him, maybe 800–1000 people, which at any other conference would be huge numbers. His audience, however, is dwarfed by the rock star presenters of this convention, the masters of couple therapy! Walk into almost any presentation, panel, or conversation hour with John and Julie Gottman, Harvelle Hendrix and Helen LaKelly Hunt, Susan Johnson, Esther Perel, or Michele Weiner-Davis, and the room is packed, double the audience of many other presenters. This will not be a surprise to working therapists, and it should be a heads-up to students preparing to enter the helping professions. More and more couples are coming to therapy, seeking help for themselves and their relationship. Accordingly, knowing how to work with couples has become the new “must-have” skill in therapy. Even those presenting for individual therapy often shift immediately into relational issues that make it all but certain a coupled partner should be invited to join the therapy sessions. It turns out that Adler (1932) was right: we are social beings, whether we like it or not. We are challenged as a result of our evolutionary limitations and restrictions to form into communities, to take care of each other, to form a common bond. As John Dewey (1916) noted:

T

here is more than a verbal tie between the words, common, community, and communication. [People] live in a community in virtue of

Foreword  xv

the things which they have in common; and communication is the way in which they come to possess things in common. (p. 4)

So, we are social beings, and we have to learn to work together, to cooperate, to divide and exchange labor fairly and freely, to make a contribution. In short, we have to find something meaningful to do with the time that we have on earth, and the meaning we achieve, individually or together, is directly related to the contribution we make to the larger whole of humanity. The social task provides the context for answering the question “Who am I?” How we use our time on earth answers the question “What am I worth?” When individuals retreat from the challenge of meeting these tasks, when they turn in upon themselves, let fear overwhelm them, seek isolation, they become disordered, discouraged, disengaged. Distress and impairment in these areas is a fundamental aspect of psychopathology. The same evolutionary demands for survival and adaptation that require the psychological capacity for friendship (community) and cooperation (work) also build into our very being the desire to couple, to love and be loved by at least one other person, to feel safe and no longer alone, as we make our way in the world and through life. This need for intimacy is, of course, connected to the species requirement for procreation, but the earth has more than enough people on it. Indeed, the world might actually be better off if only about a fourth of earth’s population had children for the next few generations. Even so, the need for intimacy would still be present in all of us. So, we couple. From birth on, at least one parent couples with the child, forming an intimate bond. This is attachment, and the capacity for that child to engage in later bonding is literally set in motion by this relationship. Contact and emotional/physical attunement turn out to be almost everything. If the child has more than one parent, regardless of gender or genders involved, the bond between those parents also creates a model for relational processes, for how get along with ourselves, members of the same sex, members of the other sex, and how to handle the experiences related to race, ethnicity, culture, gender and gender identity, sexual/affectional orientation, and ableness, to name just a few of the challenges and influences that permeate modern life. In short, we learn to love and bond in dyads, to call these coupled relationships home, and then to move out into the world, to engage and work there, but always to have this home to which we regularly, if not daily, return. When these bonds fail to develop in childhood or are ruptured over time, when people are hurt or neglected, abused or violated, or when the adults in a child’s life are disordered, the chances that such children will grow into healthy adult bonding are greatly diminished. Indeed, the likelihood of individual psychological disorders increases in these individuals. Today, people who come for couple therapy can roughly be divided into two groups, as this book notes. There are those who essentially have relational

xvi Foreword

issues and need to sort through communication and problem-solving processes. The second group involves more severe problems in which one or both partners in the relationship meet criteria for often multiple psychopathologies, as delineated within the DSM-5 (American Psychiatric Association, 2013). Again, as the authors in this book point out, it is not just that these psychiatric disorders get played out in couples, but also that the stress and demands of the coupled relationship can actually exacerbate the individual disturbances. The good news is that the coupled relationship can also be the avenue for therapy, but not if the actual psychiatric disorders are missed, misdiagnosed, or ignored. It is, by the way, this latter group, these more severely disordered couples, which are increasingly walking through our doors. The authors in this book cover the myriad of ways in which people couple differently. The discussions of cultural differences, same-sex marriages, and developmental stage-of-life relationships, alone, are worth the reading of the book. The heart of the book, however, is the 13 chapters that address psychological disorders in couples ranging from anxiety, depression, and psychosis to personality disorders, addictions, and violence. From my position as a counselor and an academic, I believe that there is no one better at assessment and case conceptualization with couples than Len Sperry. And his model is applied throughout these chapters. Each of the disorders addressed extends biopsychosocial clinical formulations into cultural considerations and the reflexive influence of coupling and psychopathology. Each disorder, properly conceptualized, informs a careful delineation of treatment. As couple therapy inevitably leaves the confines of private practice and becomes more and more incorporated into mental health agencies and integrated care practices, this is the manual for the future. This is the book that will support core training in the helping professions. Couple counselors and marital therapists—in private practice or in agencies—social workers; couple/marital psychologists; psychiatrists and psychiatric nurses; pastoral counselors: get ready. These are the couples we will be serving for the next 25 years. James Robert Bitter, Ed.D. Professor of Counseling and Human Development East Tennessee State University Author: The Theory and Practice of Family Therapy and Counseling (2014) References Adler, A. (1932). What life should mean to you. London: George Allen and Unwin. American Psychiatric Association. (2013). The diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author. Dewey, J. (1916). Democracy and education. New York, NY: Palgrave Macmillan.

INTRODUCTION The Changing Landscape of Couple Therapy Today and Tomorrow Katherine Helm and Len Sperry

T

he first edition of this book was published in 1998. It was unique in that it was the only book that addressed psychopathology in one or both partners in committed intimate relationships. Since then, several important trends in the field of mental health and couple therapy have occurred, making a revision of this text timely. Some of these trends include: the influence of social media and technology on one’s “couple identity,” problems and status, the legalization of same-sex marriage, increases in the availability of Internet pornography and increasing Internet infidelity, changes in the norms regarding romantic relationships (e.g., hook-up culture, cultural trends in the Millennial generation that impact one’s commitment to romantic relationships), decreasing marriage rates, and increasing acceptance of non-traditional romantic relationships (e.g., cohabitation). Other influences on couples work today include: the demonstrated effectiveness of couple therapy; more randomized controlled trials (RCTs) and empirically validated/evidence-based treatments for specific types of couple therapy; current research on the critical importance of the therapeutic alliance with the treating counselor, as well as specific ways it might differ between male and female partners (and the impact this can have on the effectiveness of the couple therapy); increased research on couple therapy where one partner has a comorbid psychological disorder; and a new edition of the Diagnostic and Statistical Manual, DSM-5. These and other twentyfirst century trends are shaping the structure of couples and families in rapidly changing ways, which impact the mental health and presenting issues of couples. Couples clinicians are taught how to do couple therapy; however, the majority of therapeutic models still do not adequately address the unique treatment issues that exist when one or both members of a couple present

2  Katherine Helm and Len Sperry

with psychopathology. The first edition of this text was foundational in the marriage and family field, bringing together critical information about the presentation, treatment, and challenges faced by couples struggling with high levels of psychopathology. There continue to be very few texts available to guide clinicians and counselors-in-training in the treatment of disordered couples. The second edition maintains this focus on disordered couples; however, new features are added, making it even more timely. The disorders covered in this book reflect DSM-5 categories and language. This edition of The Disordered Couple also explores the current literature on how clinicians can effectively work with disordered couples in counseling. It reviews clinically relevant practices, specific intervention strategies, and assessment recommendations for working with different types of disordered couples. Multicultural considerations are integrated into each chapter topic to provide clinicians with specific suggestions for culturally competent practice with couples. Myths About Couples and Therapy Despite the increasing research on relationship functioning and the couple therapy approaches and interventions, a number of myths about couples and couple therapy persist. We have found that addressing these myths directly helps clinicians better conceptualize and contextualize the practice of working therapeutically with couples. Table 1.1 summarizes these myths. Table 1.1  Myths Involving the Practice of Couple Therapy (Len Sperry) 1. All couples’ basic needs are essentially the same irrespective of race, ethnicity, or social class. 2. Communication work has been and should remain the primary focus and intervention in couple therapy irrespective of race, ethnicity, or social class. 3. Couple therapy is a specialized form of family therapy and cannot be ethically and effectively practiced without formal training and supervision. 4. Using the DSM-5 in couples work is not compatible with systemic (systems) thinking. 5. If one partner experiences a DSM-5 disorder, it is best treated in individual therapy rather than in couple therapy.

To the extent to which therapists and trainees hold these myths, this book is unnecessary. Until these myths are relinquished, therapists and trainees cannot be successful in treating the majority of couples that present for conjoint therapy today. This book undercuts these myths and provides the reader with an evidence-based perspective and effective set of interventions for working with a wide range of disordered couples.

Introduction  3

Myth 1: All Couples’ Basic Needs Are Essentially the Same Irrespective of Race, Ethnicity, or Social Class Given the current literature on intimate relationships, we know that race, ethnicity, culture, sexual orientation, and many other types of variables significantly shape the couple, their relationship, and even their goals for couples counseling. Previous work with couples did not adequately explore the unique needs and experiences of racially/ethnically diverse couples nor same sex couples. In this edition of The Disordered Couple, we have attempted to include much of the updated literature and culturally sensitive approaches that incorporate the critical context of how a couple’s background shapes their issues together as a couple. Dr. Eli Finkel’s book The All or Nothing Marriage (2017) demonstrates that there are significant differences between three marriage types typically seen in Western cultures: necessity, companionate, and actualization. (1) necessity (marriage out of survival needs or as a cultural expectation or demand); (2) companionate (a marriage of mutual interest and goals and shared social networks); and (3) actualization (a desire for our significant others to help us grow into a better version of ourselves and to reach our full spiritual, intellectual, emotional, and psychological potential through our romantic partners). This has become a modernized Western expectation for many couples entering marriage. Finkel suggests that for marriages that can perform this function, they are likely to be successful, but for other marriages, this expectation may put an unfair burden on the relationship as this may be unattainable and/or unsustainable. A couple’s expectation for their relationship is strongly influenced by their culture, race, sexual orientation, level of education, and socioeconomic status, as well as myriad other influences. This edition of The Disordered Couple incorporates a socio-cultural lens for effective couples work. Myth 2: Communication Work Has Been and Should Remain the Primary Focus and Intervention in Couple Therapy Irrespective of Race, Ethnicity, or Social Class Historically, couples counseling has often focused on improving couples’ communication as a hallmark of couples treatment. Although no practitioner working with couples would state that having couples communicate in more effective ways with one another is not a worthy goal, most current successful couples treatments have moved away from this goal as the most important part of couples work (e.g., emotion-focused couple therapy, Gottman’s Sound Relationship House approach, cognitive–behavioral couple therapy, etc.). These therapies (reviewed more extensively through this text) instead use empirically validated methods to help couples emotionally connect with one another and use their attachment to each other in emotionally corrective ways (EFCT); explore the most destructive aspects of communication and

4  Katherine Helm and Len Sperry

relational disconnection and teach them how to reconnect with one another through shared meaning (Gottman’s method); and help couples understand ways they influence and shape one another as well as how the context (environment) in which they exist impacts their relationship with one another. Myth 3: Couple Therapy Is a Specialized Form of Family Therapy and Cannot Be Ethically and Effectively Practiced Without Formal Training and Supervision The reality is that couple therapists come from many different professional backgrounds (e.g., MSW, Ph.D., Psy.D., MFT, M.A., etc.), and many are neither formally trained in family therapy nor licensed as marital and family therapists. While working with couples necessitates a high level of competence and training, that training can come (and often does) when a mental health professional’s formal education concludes. For example, competent couple therapists often receive specialized couple training from clinical supervisors, professional workshops, consultation, and other forms of professional development. In short, mental health professionals from diverse training backgrounds can and do work effectively with couples. Myth 4: Using the DSM-5 in Couples Work Is Not Compatible With Systemic (Systems) Thinking Like family therapy, couple therapy approaches have traditionally viewed couples from a systemic and contextual perspective. Seldom have couples’ disordered presentations been viewed from a psychopathology perspective. Perhaps, this is why the first edition of this text was successful—couple therapists were looking for strategies to more effectively help couples where at least one member was struggling with a disorder. DSM-5, though an imperfect document, is not only empirical but also significantly shaped by current thinking, culture, and social norms—all of which are systemic and contextual. DSM-5 does not exist in an unchanging vacuum and can be useful in couples work, when appropriate. Often, it can be used as a tool for helping couples understand how symptoms manifest, which can better prepare them to cope and recognize how symptoms one partner experiences influence their relationship as a whole. Increasingly, many doing couples work find that the DSM’s description of symptoms and criteria can provide couples a common language and understanding of a particular disorder (e.g., depression), especially when utilized within couple therapy with a trained professional. Myth 5: If One Partner Experiences a DSM-5 Disorder, It Is Best Treated in Individual Therapy Rather Than in Couple Therapy Many therapists, particularly those formally trained in family therapy, have a conflictual relationship with the DSM 5. As professionals, we recognize

Introduction  5

the critical importance of having a diagnostic manual that enables us to effectively recognize symptomatology, clarify a diagnosis, and speak in the common diagnostic language of our profession, but given that clinical work with individuals and couples have emerged as somewhat different modalities, often couple therapists wish to “leave that DSM-5 stuff ” for individual therapists working with diagnosable disorders. Our review of the literature in Chapter  1 tells a very different story. Current literature finds that couple therapy is quickly becoming a place where couples work together to not only strengthen their relationship but also develop a greater degree of understanding when one or both of them struggle with a psychological disorder (e.g., depression). Some literature (see Chapter  1) has found that couple therapy can be highly effective in the treatment of certain psychological disorders, and thus couple therapists should be prepared to work with psychopathology of the individual and the couple within couples work. Often when couples are emotionally and/or financially stressed and are pressed to choose between individual and couples work, they frequently choose couples work. Thus, the field has adapted its approaches to working with disordered couples in couple therapy. This book is therefore timely. Format of the Book and Intended Audience This book will explore clinically relevant practices for working with different types of disordered couples and include specific intervention strategies and assessment practices. This particular text is intended for practicing clinicians as well as counselors-in-training. We assume the reader has some basic knowledge of couples treatment and psychological theory and uses this text to supplement their knowledge and to directly apply it to work with disordered couples in treatment. Each chapter reviews a different type of disordered couple and provides a basic description of the type of couple being discussed. An overview of relevant literature to specific types of disordered couples is provided. The DSM-5 diagnostic criteria for the disorder experienced by the couple will be reviewed and a couple case conceptualization presented to augment clinicians’ understanding of how to apply the interventions discussed in each chapter. Specific assessment recommendations are made and cultural considerations for diverse couples and for operationalizing culturally competent practice will be discussed. Finally, each chapter contains a case example illustrating theoretically grounded interventions and other treatment considerations; a summary of recommendations for each disordered couple is given at the end of each chapter. The book is divided into four sections. In Part I, “Treating Disordered Couples Today,” current issues such as technology’s impact on couple relationships, Internet infidelity, and social media are explored. Additionally, the current literature on the alliance between couple therapists and couples, family-of-origin issues, and cultural issues in couple therapy (including

6  Katherine Helm and Len Sperry

same-sex couples) are reviewed. Part II, “Disordered Couples,” discusses disordered presentations in one or both partners in terms of DSM 5 categories. Part III, “Developmental Issues Impacting Couples,” reviews developmental and other relevant issues impacting couples today (e.g., the sandwich generation challenges, terminal illness, etc.). Finally, the last section, “Treating Disordered Couples: Retrospective and Prospective,” suggests future directions for couples work and a summary of this text’s most powerful conclusions for couples’ practitioners. Conclusion As already noted, several significant trends in the past two decades have necessitated a revision of this text. The most important features of this second edition include its broadened focus on many different types of couples, specific culturally sensitive considerations for providing couple therapy, and its inclusion of updated case studies to include the most current couple therapy practices and considerations in treating couples today. Additionally, this edition incorporates issues for the sandwich generation, how technology impacts couple relationships, and the future directions for couple therapy. Reference Finkel, E. J. (2017). The all-or-nothing marriage: How the best marriages work. New York, NY: Penguin Random House.

PART I

Treating Disordered Couples Today

1 ISSUES AND TREATMENT CONSIDERATIONS IN COUPLE THERAPY TODAY Katherine Helm

A

Couple Distress and Psychopathology

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

10  Katherine Helm

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 narrowband 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

Issues and Treatment Considerations  11

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,

p

oorer 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

12  Katherine Helm

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

Issues and Treatment Considerations  13

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.

D

ifferent 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 evidencedbased 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

14  Katherine Helm

(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.

Issues and Treatment Considerations  15

Family–of-Origin Issues Impacting Couples There has been extensive research on the impact of family-of-origin (FOO) issues on individuals and couples. Family-of-origin issues have been found to have significant effects on: marital satisfaction and marital quality, positive or negative attributions about one’s partner (Martinson, Holman, Larson, & Jackson, 2010: Sprenkle, 2012; Knapp, Norton, & Sandberg, 2015a; Topham, Larson, & Holman, 2005; Knapp, Sandberg, Novak, & Larson, 2015b; Hardy, Soloski, Ratcliffe, Anderson, & Willoughby, 2015; Gardner, Busby, Burr, & Lyon, 2011), and the ability of partners to self-regulate (i.e., the aptitude of romantic partners to observe relationship activity patterns and actively engage in sustaining a healthy romantic relationship (Halford, Lizzio, Wilson, & Occhipinti, 2007 as cited in Knapp et al., 2015b)). Additionally, utilizing self-regulation leads to increased marital satisfaction, higher levels of commitment within the marriage, and increased marital stability and quality (Knapp et al., 2015b). Early patterns of attachment within one’s families of origin have been found to be predictive of and influential in marital quality and satisfaction.

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ongitudinally, adult romantic attachment has been linked to previous negative experiences in family background settings. Negative life experiences within one’s FOO context are significantly related to attachment style. In other words, attachment styles developed in childhood significantly relate to adult attachment style. (Waters, Merrick, Treboux, Crowell, & Albershei, 2000 as cited in Knapp et al. 2015b, p. 132)

These findings have significant implications for couple therapy. Obviously, couple therapists need to assess for attachment style and FOO issues early in couple therapy. Individuals who did not grow up with secure attachments can find comfort in that developing a secure attachment in one’s romantic relationships can have a healing quality, and marital attachment patterns in couple therapy can be changed. EFT is especially well-suited to do this, given that its works with adult attachment style and emotional understanding from both members of the couple. Cultural Issues in Couple Therapy Multicultural counseling is often referred to as the fourth force of counseling. This deeply important lens with which to view all clients who present to counseling cannot be understated. Culture can be broadly defined as the customary beliefs, social forms, and material traits of a racial/ethnic, religious, or social group that impacts one’s worldview, self-and-other identity, values, behavior, and the very way in which we live our lives. Utilizing a multicultural lens can help couple counselors acknowledge and understand the

16  Katherine Helm

myriad intersectionalities (e.g., a middle-class African American lesbian) that occur within each individual as well as each couple. Fully integrating a multicultural perspective allows couple counselors to practice culturally competent and sensitive couple therapy. This perspective necessitates counselors’ examination of their own assumptions and values and encourages the development of an acute awareness of how cultural issues impact their views of their clients, their clients’ views of them, and the complex interaction between all of these variables. Over the last two decades, couple therapy has improved its efforts to include the study of more diverse couples within the literature. Poulsen and Thomas (2007) conclude that family and couple therapy has undergone a powerful transformation that encourages couple therapists’ understanding of how social constructivism (i.e., the ways we make meaning and interpret the world based on the social context in which we exist) impacts a particular couple’s issues. Couple counselors bring their culture, values, and beliefs to the therapy setting, and counselors have an ethical obligation to acknowledge how these factors impact the counseling process (Wylie  & Perrett, 1999). Although culture incorporates so many variables (e.g., race, ethnicity, identity, age, ability status, socioeconomic status, sexual orientation, gender identity, geographical locale, nationality, etc.), this book will narrowly focus on couple counseling with heterosexual, gay, lesbian, bisexual, African American, Latino/a, Asian American, interracial/intercultural, and religious/spiritual couples, as well as on how socioeconomic status can impact the couple counseling process. This by no means represents the full spectrum of diversity among couples. Obviously, most clinicians know that taking into account all of the cultural variables that exist is impossible and often overwhelming; however, being respectful of cultural differences as well as of how various cultural variables can impact the couple counseling process (for the couple and the counselor) is imperative to the success of couple counseling. Couple counselors who bring with them an awareness of how cultural context impacts couples’ relationships and the process of couple therapy may be able to more effectively build an alliance with these couples. Bhugra and De Silva (2000) acknowledge that cultural differences are especially challenging in couple therapy because of the multitude of ways they can manifest. They caution couple therapists to be aware of how cultural differences can shape the power dynamic in therapy (e.g., if the counselor is from a majority cultural background and the couple is Latino/a). Much of the literature recommends that couple therapists address cultural differences early and often throughout the relationship, which serves to build trust between the couple and counselor and models for couples that challenging and sensitive issues within the setting can be discussed (Poulsen & Thomas, 2007; Bhugra & De Silva, 2000). Mirkin and Geib (1999) encourage the use of inquiring questions that explore meaning rather than imposing meaning on couples, which can help establish a collaborative working alliance.

Issues and Treatment Considerations  17

The downside to grouping all cultural groups together under the umbrella of “multiculturalism” is that counselors can get lulled into: (1) underestimating the cultural distinctiveness of each group from other groups; (2) believe that “being culturally sensitive” and “open” is enough to work with any group instead of relying upon one’s own individual research about group values and other variables specific to each group; (3) making broad generalizations about certain groups without recognizing and respecting the significant heterogeneity of each individual and couple, even if the counselor him/herself is a member of a similar diverse group as the couple; (4) not exploring the distinctiveness within European American groups and not considering this group to have a valid culture when they present for couple counseling; and (5) becoming overwhelmed by all of the knowledge needed to work with diverse groups. Couple counselors should guard against these temptations and recognize that attaining cultural competence as a counselor is a lifelong process and a continual effort. African American Couples There is a paucity of literature on the unique experiences and struggles of Black couples. To provide therapy to African American couples as though they are the same as couples from other backgrounds will lead to ongoing treatment failure (Helm  & Carlson, 2013). African American families are far more likely than European American families to have a non-traditional family structure (e.g., female-led, three generations living together, nonrelated family members helping to raise children). Helm and Carlson (2013) find that the literature suggests that Blacks highly value marriage, and many report a desire to be married; however, Blacks, independent of educational level, tend to marry at later ages than their white counterparts (28.6 for Black men and 28.1 for Black women versus 27.2 for white men and 26.6 for white women), and many Blacks are simply declining marriage overall. Married, non-or-never married, and remarried Black couples are likely to present for couple counseling. Blackman, Clayton, Glenn, Malone-Colon, and Roberts (2005) produced a groundbreaking review, The Consequences of Marriage for African Americans: A Comprehensive Literature Review, that found that many of the reasons Black couples come to counseling include that they recognize the economic, psychological, intimacy, and social benefits of marriage and long-term romantic relationships and also see this as important to raising children. Couple counselors should be aware that African American couples report lower marital satisfaction than their white counterparts. The myriad reasons that contribute to this are beyond the scope of this book; however, in working with African American couples, couple counselors should keep the following general principles in mind: (1) the legacy of slavery, oppression, racism, and discrimination continues to negatively impact the lives of Black couples, and couples may unconsciously take out daily racialized stressors

18  Katherine Helm

on one another; (2) Black couples may be more religious than majority couples and may prefer to receive guidance from religious personnel; (3) some Black couples may have a distrust of mental health professionals because of the history of these systems pathologizing them; (4) Black couples may have been socialized to “keep the family business” within the family and may not wish to share “family secrets” with the couple therapist; (5) therapist “joining” with the couple is critical to the success of couple counseling; and (6) Black couples have been found to respond best to strength-based approaches in couple counseling (Helm & Carlson, 2013) Latino/a Couples Many Latino/a couples face unique challenges that can impact their romantic relationships. Some of those challenges may include: immigration status and potential loss of emotional resources (Perez, Brown, Whiting, & Harris, 2013), SES, level of acculturation, racism, discrimination, and microaggressions. Obviously, how a couple copes with these stressors can impact the health of the couple relationship and its very survival. Latino couples can come from many different cultural backgrounds (e.g., Columbian and Mexican); thus, culturally competent practice encourages couple counselors to assess and understand the many cultural differences that may be operating within the relationship. Perez et al. (2013) studied Latino couples’ response to relationship education programs and found that programs taking into account specific cultural values were important. The program was offered in Spanish. Cultural values that were found to affect the couple relationship in this study included: familismo (the importance of family and children); cultural obligation (collectivism and obligation to one’s cultural group; the desire to bring their knowledge about healthy marriages into the wider community); machismo (often referred to as excessive maleness and values and behaviors extending from this gender identity)/marianismo (feminine identity and values and behaviors extending from this, including purity, strength, and being more subdued—as if imitating the Virgin Mary)—both refer to gender roles and/or differences in some Latino couples; and fatalism (how fate impacts individuals; i.e., things happen for a reason and/or there is a greater power at work in one’s life) (Perez et al., 2013). Couples in this study also benefitted from the social support provided by other couples. Asian/Asian American Couples As with other couples of color, Asian/Asian American couples may have different values that couple counselors need to be aware of that may be different from majority couples. Similar to Latino couples, Asian/Asian American couples may be impacted by immigration status and potential loss of emotional resources, SES, level of acculturation, racism, discrimination, and microaggressions. Western and Asian/Asian American couples may differ in

Issues and Treatment Considerations  19

certain cultural values, such as the dimension of individualism–collectivism, which “describes the extent to which a culture encourages individual needs, wishes, desires, and values versus group and collective ones” (Masumoto, 1991 as cited in Hiew, Halford, van de Vijver,  & Liu, 2015). These differences can shape a couple’s relationship beliefs and behavior and expectations for love and psychological intimacy, which may be less important for Asian American couples higher on collectivism. For Chinese couples, the self may be defined by relationships with others, and self-worth may be tied closely to “face” (positive social image; Gao & Ting-Toomey, 1998). Values such as the maintenance of harmonious relationships, dependence on family, and multigenerational familial relationship obligations are often more important to marital satisfaction than emotional intimacy with one’s partner, as is the case with Western couples (G.M. Chen, 2001). Many of these values differences may depend on how highly acculturated the couple is, and couple counselors should remember that members of a couple can have different levels of acculturation. Asian American couples may endorse a more traditional gender-role ideology than Western cultures. In their study comparing Chinese, Western, and Chinese–Western intercultural couples, Hiew et al. (2015) found that compared to Western couples, who endorsed relationship standards based on individualistic ideals of romantic love and psychological intimacy (defined as couple bond), Chinese couples more strongly endorsed relationship standards based on collectivistic and embedded ideals regarding relations with extended family, face, relationship harmony, and traditional gender roles (defined as family responsibility). When working with Asian/ Asian American couples, counselors should keep several things in mind: (1) level of acculturation of each member of the couple; (2) where couples sit on the individualism–collectivism value continuum; (3) cultural identity of each member of the couple; (4) common values specific to Asian cultural groups; and (5) the immense diversity of Asian cultures and cultural values distinctions. Unfortunately, there continues to be limited research about Asian/Asian American couples. Interracial and Intercultural Couples Though it is true that there are more interracial couples today than in previous decades, Leslie and Young (2015) report that studies of marital satisfaction and longevity suggest that, in general, interracial couples experience lower marital satisfaction and stability than same-race couples (Bratter  & King, 2008; Hohmann-Marriott  & Amato, 2008). There are many reasons interracial couples may experience unique challenges, including: lack of family, peer, and societal support for the relationship; internalized stereotypes about specific racial groups that can unconsciously impact the relationship; differential racialized privilege in society that impacts the couple as a unit and both members of the couple individually in different ways; experiencing

20  Katherine Helm

the relationship as a racial betrayal of members of their own racial group; not talking about racial issues within the couple relationship; and neglecting the other partner’s perspectives on how being an interracial couple impacts the relationship (Leslie  & Young, 2015). Obviously, interracial couples also present to counseling with issues similar to other couples, including communication issues; negotiating gender roles; maintaining a loving, trusting relationship; and other issues. With interracial couples, couple counselors should help the couple facilitate dialogue about the ways in which being an interracial couple may have impacted their relationship. Leslie and Young (2015) find that couples often do not do this. These authors do find that interracial couples are often good at “banding together” when they experience discrimination, but they may be less good at acknowledging their different values and experiences based on race and how these issues impact them as a couple. Finally, couple counselors should encourage couples to have conversations about racial privilege, the impact of microaggressions (regularly experienced slights/insults that impact members of oppressed groups and can be stressful), and values that may be culturally based (Leslie & Young, 2015). Muslim Couples Another developing area of couples counseling work is with Muslim couples. According to the U.S. State Department, Islam is one of the fastest growing religions in the United States (Daneshpour, 2009) and is currently the second largest religious group (Sauerheber, Nims,  & Carter, 2014). The needs of these couples are shaped by several factors, including shared discrimination, the marital expectations set forth by an Islamic belief system (which makes these marriages different than other religious groups), cultural differences and differences in the ways Islam is practiced, the way marriage partners are selected (which can significantly differ from Westernized ways of partner selection), the importance of collectivism as a value (including extended family support), traditional gender roles, shared meanings about Allah, the view that marriage is a sacred contract, and other factors (Sauerheber et al., 2014). Counselors should be mindful that Muslim couples may come from very different cultural/ethnic backgrounds (e.g., Palestine and Qatar), which can also impact their relationship. Prior to marriage, opposite sex mingling is often highly discouraged, especially without adult supervision (Springer, Abbott,  & Reisbig, 2009), and mate selection is highly influenced by one’s family values, religious practices, education, and community (Asamarai, Solberg, & Solon, 2006 as cited in Sauerheber et al., 2014). Similar to Asian/ Asian American couples, Muslim couples may be impacted by immigration status and potential loss of emotional resources, SES, level of acculturation, racism, discrimination, and microaggressions. Sauerheber et al. (2014) point out that seeking couple therapy for Muslim couples takes significant courage, as seeking professional counseling may include a sense of failure in not

Issues and Treatment Considerations  21

keeping the tenants of their faith regarding the marital relationship. Additionally, there may be a strong cultural value to keep any conflicts within the family. Muslim couples may present with intergenerational issues, emotional distress, an obligation to honor one’s faith and family, and potential values conflicts between Islamic religious tenants and Westernized cultural values. While working with Muslim couples, couple counselors should understand some of the basis tenants of Islam and how marriage is situated within the practice of Islam, where the couple lies on the individualism– collectivism continuum, the multigenerational expectations of family, the impact of discrimination on the couple, and gender roles, and should also be sensitive to other definitions of healthy marital relationships outside of Westernized norms. Same-Sex Couples Same-sex marriage was legalized in the United States in 2015. The research on couple therapy with same-sex couples is significantly lacking, and couple treatment for same-sex couples remains based on heterosexual couples models, with few exceptions. There is a significant paucity of research on transgender couples work, which is why we are unfortunately unable to include transgender couples in this text. Bernstein (2000) states that “few mainstream heterosexual therapists are properly prepared or trained to cross the cultural divide that presents itself when working with couples of different sexual orientations” (as cited in Poulsen & Thomas, 2007, pp. 149–150). This is highly problematic, as many couple counselors are not adequately prepared to work with same-sex couples in sensitive and knowledgeable ways. As with all couples, couple counselors need to be clearly aware of the context in which the couples’ relationship exists. For same-sex couples, this is complicated by several factors. One, same-sex relationships do not receive the same level of societal validation and support as heterosexual relationships (Connolly, 2004). Most individuals in same-sex couples have grown up surrounded by heteronormative ideas of gender and romantic relationships, which do not fit the model for their relationships. Couple counselors need to examine their own beliefs about gender, heteronormativity, and romantic relationships. Long and Serovich (2003) assert that couple and family therapists need to learn to critically evaluate the heterosexist bias in which most were trained, including the models most frequently utilized for the treatment of couples and families. Two, same-sex relationships continue to exist against a backdrop of oppression. Same-sex couples may struggle to find support for their relationship among family, peers, and society as a whole. The day-today impact of this on couples’ relationships can be extraordinary. Additionally, partners within the couple may differ in terms of their identity, when they came out, and how comfortable they are with sharing the relationship with others, as well as how much they wish to include their families in their

22  Katherine Helm

romantic relationships. Connolly (2004) states that same-sex couples seek couple therapy for many of the same issues as all couples, including:

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ommunication problems, infidelity, substance abuse, and decisionmaking about staying together or separating; however, the predominant issues that distinguish gay, lesbian, and bisexual same-sex couples from heterosexual opposite-sex couples are the impact of gender role socialization and the societal oppression generalized as homophobia and heterosexism [the belief that heterosexual relationships are superior to, and the only legitimate form of romantic relationship]. (p. 4)

Same-sex relationships can be further complicated if one member of the couple identifies as gay or lesbian and the other identifies as bisexual. This difference in identification can lead to conflicts, because the bisexual member of the couple could be viewed as having access to heterosexual privilege. Additionally, there could also be some mistrust if the identity differences have not been discussed and explored within the couple’s relationship. Male same-sex partnerships often receive a stronger negative reaction than female same-sex relationships. Couples, given the heteronormative socialization process, could be at risk for internalizing homophobia and heterosexual gender norms. Same-sex couples also deal with the intersectionality of multiple identities (e.g., out at home but not at work, same-sex couples of color or interracial same-sex couples, etc.). These couples also have to deal with the notion that the coming out process is a lifelong, continual process. This is but a brief overview of the complicated issues that impact same-sex couple relationships. According to Connolly (2004), some couples, due to lack of same-sex couple models, may struggle with what their relationships should “look” like. She states that

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hrough the discovery of the contextual pieces of individual, couple, and generational stages, culture and ethnic variables, and the couple’s negotiation and mobilization of family, friend, and community support, we have an increased chance of recognizing and understanding the broader and deeper clinical issues affecting same-sex couples and the issues they present in therapy. (p. 10)

Socioeconomic (SES) Issues in Couple Therapy Americans in general, often are not in tune with classism. Some of this may be due to the founding ideals of the nation itself, in which the founding fathers espoused “liberty, and justice for all” in spite of major class differences within the population. The existence of class differences is

Issues and Treatment Considerations  23

pervasive and often silent in the therapy room. Culturally competent counselors are often better prepared to recognize racial, ethnic, sexual orientation, gender, and other types of class differences, but the profession as a whole is largely centered in a middle-class, Eurocentric worldview. Poulsen and Thomas (2007) caution couple counselors to treat SES as a cultural variable (instead of a demographic variable) that manifests in a variety of ways in counseling, including: educational differences, blue collar vs. white collar distinctions, assumptions counselors and clients alike make regarding finances, differing access to resources, and other values. As with other cultural factors, couple counselors need to examine their own attitudes about social class, influences from their families of origin regarding SES, and make an effort to understand how financial struggles may impact the couple’s relationships. Couple counselors should also keep in mind that just like race and sexual orientation, SES can be an identity variable and significantly shape how clients view themselves and define their respective experiences. Obviously, SES is far more than how much money an individual or couple make—it comes with a whole host of values, assumptions, and differing levels of power. Finally, SES often shapes one’s view of counseling as well as one’s access to resources, such as childcare, education, and housing. Often, the more money an individual has, the more resources they have access to. Remarital Couple Therapy Divorce, remarriage, and non-married cohabitating couples are far more common today than they were two or three decades ago. These relationships were often excluded from research on traditional couple therapy. Remarried couples face some unique concerns, given that this may be a second marriage for one or both partners. Statistics reveal that 40–50% of legal messages are remarriages for one of both partners, and about 65% of those remarriages include children from a former relationship (Michaels, 2007). Michaels (2007) reports distinctive issues remarried couples deal with, including: role and boundary ambiguity (especially for a partner assuming a step-parenting role), unrealistic expectations, and issues with family adjustment, especially when children are involved. Remarried couples may have unrealistic expectations surrounding children’s adjustment to step-parenting and children’s ability to negotiate multiple sets of expectations in different households. Michaels (2007) cautions couple counselors to understand that remarriages often follow multiple losses. Approximately 30% of adults remarry within one year of their divorce; because most females are far more likely to be the custodial parent, if they remarry male partners, he is often thrust into the step-parenting role. Research demonstrates that many stepfathers have an emotionally distant relationship with their step-children, which is often encouraged by the children themselves (Michaels, 2007), and

24  Katherine Helm

that this relationship rarely improves over time. Remarried couples report a lower level of marital satisfaction and have higher levels of negativity in terms of problem solving and conflict resolution (Hetherington, 1993). Remarried families may try to model themselves on the traditional nuclear family, which is often problematic and does not allow remarried families to adjust to the new family dynamic. Often the non-custodial parent’s role (frequently the biological father) significantly diminishes over time, which can be another loss for the children (Michaels, 2007). When biological fathers remain involved in their children’s lives post-divorce, they have a positive influence on children’s ability to adjust to the step-family. Often the divorced parents’ ability to negotiate, communicate, and have clear interactions with one another around child-raising expectations predicts a more positive outcome for children and the non-custodial parent’s consistent involvement in the children’s lives (Michaels, 2007). Clearly, remarried couples face unique struggles, and couple therapists can best help these couples if they are aware of and sensitive to the challenges these families face. Conclusion This chapter has reviewed the most current literature in couple therapy and treating disordered couples. It serves as the context in which chapter authors will explore couples with differing psychological disorders. Each chapter will review cultural implications on the types of psychological disorders discussed in this book as well as investigate the most current treatments for working with disordered couples. References Asamarai, L. A., Solberg, K. B., & Solon, P. C. (2006). The role of religiosity in Muslim spouse selection and its influence on marital satisfaction. Journal of Muslim Mental Health, 3, 37–52. Baucom, D. H., Epstein, N. B., LaTaillade, J. J., & Kirby, J. S. (2008). Cognitive–behavioral couple therapy. In A. S. Gurman (Ed.), Clinical handbook of couple therapy (pp. 31–72). New York, NY: Guilford Press. Bernstein, A. C. (2000). Straight therapists working lesbians and gays in family therapy. Journal of Marital and Family Therapy, 26, 443–454. Bhugra, D., & De Silva, P. (2000). Couple therapy across cultures. Sexual and Relationship Therapy, 15(2), 183–192. Biesen, J. N., & Doss, B. D. (2013). Couples’ agreement on presenting problems predicts engagement and outcomes in problem-focused couple therapy. Journal of Family Psychology, 27(4), 658–663. Blackman, L., Clayton, O., Glenn, N., Malone-Colon, L., & Roberts, A. (2005). The consequences of marriage for African-Americans: A comprehensive literature review. New York, NY: Institute for American Values. Bratter, J. L., & King, R. B. (2008). But will it last? Marital instability among interracial and same-race couples. Family Relations, 57(2).

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Brown, P. D., & O’Leary, K. D. (2000). Therapeutic alliance: Predicting continuance and success in group treatment for spouse abuse. Journal of Consulting and Clinical Psychology, 68(2), 340–345. Chen, G. M. (2001). Towards transcultural understanding: A  harmony theory of Chinese communication. Transcultural Realities: Interdisciplinary Perspectives on Cross-Cultural Relations, 55–70. Christensen, A., & Jacobson, N. S. (2000). Reconcilable differences. New York, NY: Guilford Press. Connolly, C. M. (2004). Clinical issues with same-sex couples: A review of the literature. Journal of Couple & Relationship Therapy, 3(2/3), 3–12. Daneshpour, M. (2009). Bridges crossed, paths traveled: Muslim intercultural couples. In T. A. Karis & K. D. Killian (Eds.), Intercultural couples: Exploring diversity in intimate relationships (pp. 207–228). New York, NY: Routledge. DeLoach, C. D. (2012). Couples therapy with African American couples. In K. M. Helm  & J. Carlson (Eds.), Love, intimacy, and the African American couple (pp. 199–228). New York, NY: Taylor & Francis. Epstein, N. B., & Baucom, D. H. (2002). Enhanced cognitive–behavioral therapy for couples: A contextual approach. Washington, DC: American Psychological Association. Gao, G.,  & Ting-Toomey, S. (1998). Communicating effectively in multicultural context; Vol. 5. Communicating effectively with the Chinese. Thousand Oaks, CA: Sage. Gardner, B. C., Busby, D. M., Burr, B. K., & Lyon, S. E. (2011). Getting to the root of relationship attributions: Family-of-origin perspectives on self and partner views. Contemporary Family Therapy, 33, 253–272. Gottman, J. M. (1998a). The marriage clinic: A  scientifically based marital therapy. New York, NY: W. W. Norton & Company. Gottman, J. M. (1998b). Psychology and the study of marital processes. Annual Review of Psychology, 49, 169–197. Gurman, A. S. (2011). Couple therapy research and the practice of couple therapy: Can we talk? Family Process, 50(3), 280–292. Halford, W. K., Lizzio, A., Wilson, K. L., & Occhipinti, S. (2007). Does working at your marriage help? Couple relationship self-regulation and satisfaction in the first 4 years of marriage. Journal of Family Psychology, 21, 185–194. Hardy, N. R., Soloski, K. L., Ratcliffe, G. C., Anderson, J. R., & Willoughby, B. J. (2015). Associations between family of origin, climate, relationship self-regulation, and marital outcomes. Journal of Marital and Family Therapy, 41(4), 508–521. Helm, K. M., & Carlson, J. (2013). Love, intimacy, and the African American couple. New York, NY: Taylor & Francis. Hetherington, E. M. (1993). An overview of the Virginia Longitudinal Study of Divorce and Remarriage with a focus on early adolescence. Journal of Family Psychology, 7(1), 39–56. Hiew, D. N., Halford, W. K., van de Vijver, F. J. R., & Liu, S. (2015). Relationship standards and satisfaction in Chinese, western, and intercultural Chinese-western couples in Australia. Journal of Cross-Cultural Psychology, 46(5), 684–701. Hohmann-Marriott, B. E.,  & Amato, P. (2008). Relationship quality in interethnic marriages and cohabitations. Social Forces, 87(2), 825–855. Jacobson, N. S., & Christensen, A. (1998). Acceptance and change in couple therapy: A therapist’s guide to transforming relationships. New York, NY: W. W. Norton & Company.

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Jacobson, N. S.,  & Margolin, G. (1979). Marital therapy: Strategies based on social learning and behavior exchange principles. New York, NY: Brunner/Mazel. Johnson, S. M. (2007). A new era for couple therapy: Theory, research, and practice in concert. Journal of Systemic Therapies, 26(4), 5–16. Knapp, D. J., Norton, A. M., & Sandberg, J. G. (2015a). Family-of-origin, relationship self-regulation, and attachment in marital relationships. Contemporary Family Therapy, 37, 130–141. Knapp, D. J., Sandberg, J. G., Novak, J., & Larson, J. H. (2015b). The mediating role of attachment behaviors on the relationship between family-of-origin and couple communication: Implications for couples therapy. Journal of Couple & Relationship Therapy, 14, 17–38. Knerr, M., Bartle-Haring, S., McDowell, T., Adkins, K., Delaney, R. O., Gangamma, R., . . . Meyer, K. (2012). Trajectories of therapeutic alliance in couple versus individual therapy: Three-level models. Journal of Sex & Marital Therapy, 38, 79–107. Knobloch-Fedders, L. M., Pinsof, W. M., & Mann, B. L. (2004). The formation of the therapeutic alliance in couples therapy. Family Process, 43(4). Lebow, J. L., Chambers, A. L., Christensen, A., & Johnson, S. M. (2012). Research on the treatment of couple distress. Journal of Marital and Family Therapy, 38(1), 145–168. Leslie, L. A., & Young, J. L. (2015). Interracial couples in therapy: Common themes and issues. Journal of Social Issues, 71(4), 788–803. Long, J. K., & Serovich, J. M. (2003). Incorporating sexual orientation into MFT training programs: Infusion and inclusion. Journal of Marital and Family Therapy, 29, 59–67. Martinson, V. K., Holman, T. B., Larson, J. H., & Jackson, J. B. (2010). The relationship between coming to terms with family-of-origin difficulties and adult relationship satisfaction. The American Journal of Family Therapy, 38, 207–217. Masumoto, D. (1991). Cultural influences on facial expressions of emotion. The Southern Communication Journal, 56, 128–137. Michaels, M. L. (2007). Remarital issues in couple therapy. Journal of Couple & Relationship Therapy, 6(1/2), 125–139. Mirkin, M., & Geib, P. (1999). Consciousness of context in relational couples therapy. Journal of Feminist Family Therapy, 11, 31–51. Perez, C., Brown, M. D., Whiting, J. B., & Harris, S. M. (2013). Experiences of Latino Couples in relationship education: A critical analysis. The Family Journal: Counseling and Therapy of Couples and Families, 21(4), 377–385. Poulsen, S. S., & Thomas, V. T. (2007). Cultural issues in couple therapy. Journal of Couple & Relationship Therapy, 6(1/2), 141–152. Sauerheber, J. D., Nims, D., & Carter, D. J. (2014). Counseling Muslim couples from a Bowen family systems perspective. The Family Journal: Counseling and Therapy for Couples and Families, 22(2), 231–239. Sprenkle, D. H. (2012). Intervention research in couple and family therapy: A methodological and substantive review and an introduction to the special issue. Journal of Marital & Family Therapy, 38(1), 3–29. Springer, P. R., Abbott, D. A., & Reisbig, A. M. (2009). Therapy with Muslim couples and families: Basic guidelines for effective practice. The Family Journal: Counseling and Therapy for Couples and Families, 17, 229–235. Symonds, D., & Horvath, A. O. (2004). Optimizing the alliance in couple therapy. Family Process, 43(4), 443–455.

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Topham, G. L., Larson, J. H., & Holman, T. B. (2005). Family-of-origin predictors of hostile conflict in early marriage. Contemporary Family Therapy, 27(1), 101–121. Waters, E., Merrick, S., Treboux, D., Crowell, J., & Albershei, L. (2000). Attachment security in infancy and early adulthood: A twenty-year longitudinal study. Child Development, 71(3), 684–689. doi:10.1007/s10826-10006-19027-z. Whisman, M. A., & Baucom, D. H. (2012). Intimate relationships and psychopathology. Clinical Child and Family Psychology Review, 15, 4–13. Whisman, M. A., Beach, S. R. H., & Snyder, D. K. (2008). Is marital discord taxonic and can taxonic status be assessed reliably? Results from a national, representative sample of married couples. Journal of Counseling and Clinical Psychology, 76, 745–755. Whisman, M. A., Snyder, D. K., & Beach, S. R. H. (2009). Screening for marital and relationship discord. Journal of Family Psychology, 23, 247–254. Whisman, M. A., & Uebelacker, L. A. (2006). Impairment and distress associated with relationship discord in a national sample of married or cohabiting adults. Journal of Family Psychology, 20, 369–377. Wylie, K., & Perrett, A. (1999). Ethical issues in work with couples. Sexual and Marital Therapy, 14, 219–237.

2 SOCIAL MEDIA AND THE IMPACT OF TECHNOLOGY ON COUPLES AND THEIR DISORDERS Kimberly Duris

T

echnology is ever-present in today’s social and romantic relationships. Whether the electronic connection is a computer, laptop, smartphone, or tablet, couples are faced with the challenge of having a third party in their relationship: the electronic device. This has resulted in couples needing to place parameters around the use of technology in their relationship (Kerkof, Finkenauer, & Muusses, 2011). Defining what a healthy amount of technology usage is in a relationship, as well as when it becomes a threat to the relationship, is an emergent issue. Online infidelity rates are also increasing. Research demonstrates that there are various personal and relationship characteristics that lend certain couples to be more prone to problematic Internet usage compared to other couples. Overall, technology has shifted the ways in which relationships are formed and maintained, resulting in new areas of growth and vulnerabilities for couples. The focus of this chapter is on the impact of social media and technology on couples’ relationships. First, relevant literature related to the use of social media and technology in relationships will be explored. Second, current treatment recommendations will be discussed, including assessment measures that can be utilized by a counselor to determine if social media, Internet infidelity, and the impact of technology on couples is problematic. Third, a sample case will be provided to illustrate the conceptualization of a couple faced with the negative impact of social media and Internet infidelity. Cultural considerations and suggestions for culturally competent practice will be reviewed. Finally, a summary of recommendations for working with these couples will be included. Overview: Theory and Research on the Use of Social Media and Technology on Couples and Their Disorders According to a study conducted in the last decade, approximately 58% of married couples have one or more computers in their home, and within

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these households, 89% of them have more than one cell phone. Seventy-five percent of people in the United States report using the Internet, with 92% of them using email as a main source of communication (Grov, Gillespie, Royce, & Lever, 2011). The increase in the use of cell phones has fundamentally changed the way that people communicate, with 31% of people preferring text messaging to phone calls. These statistics represent the most rapid increase in the use of technology in everyday life compared to previous generations (Hertlein, 2012). One theory that has been created to understand the impact of this increase in technology usage among couples is the Multi­ theoretical Model, created by Katherine Hertlein. This theory integrates three separate perspectives: the ecology perspective, the structural–functional perspective, and the interaction–constructionist perspective. These three perspectives provide a critical context in understanding how technology impacts the process and structure of family and couple relationships. The family ecology perspective focuses on how the environment impacts relationships. In addition, it looks at how the family system is influenced by societal factors, such as economic policy and issues within the immediate environment. The structural–functional perspective looks at changes to the structure of relationships. This perspective addresses how families are organized to meet the needs of each individual within the family unit. The Multitheoretical Model includes the understanding of how technology is integrated into the structure of the family, resulting in a redefinition of family rules surrounding privacy, use of time, communication, change in boundaries, and a change in family roles (Hertlein, 2012). The changes to family dynamics due to the influence of technology can also be interpreted through the interaction–constructionist perspective. This perspective emphasizes the development of family relationships through social interactions, communication, behavior, gestures, and rituals. Technology has impacted how intimacy is defined and experienced and even how relationships are formed and maintained (Hertlein, 2012). How Technology Impacts Relationships As technology continues to evolve, new vulnerabilities are introduced to couples. The Multitheoretical Model also identified seven ecological vulnerabilities couples face because of technological advances. They are accessibility, affordability, anonymity, acceptability, approximation, ambiguity, and accommodation (Seven As). Use of the Internet itself allows for anonymity due to the numerous ways in which an Internet user can mask his/her identity and personality. Deindividuation can result in people who would normally not seek out online relationships becoming more willing to do so when they can take on alternative personalities and behave in ways that they normally would not behave in person (disinhibition) (Spears & Lea, 1994). However, this can also result in people integrating problematic online behavior into their offline lives, as well, resulting in negative consequences for their

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offline relationships (Hertlein, 2012). Anonymity allows an equalization of differences related to power, gender, and social status, resulting in greater exposure to a variety of individuals of diverse backgrounds from all over the world (Spears & Lea, 1994). Ambiguity is another factor to be considered, as it can result in partners defining problematic Internet usage differently. An example of this discrepancy can be how each partner defines the viewing of online pornography or having contact with previous romantic partners via social media. Because of missing in-person communication cues such as facial expressions and tone of voice, online communication can be misinterpreted and sometimes result in a reduction of adherence to social norms and an increase in uninhibited behavior (Spears  & Lea, 1994). This can take a negative toll on a couple’s relationship. The final factor explored by the Multitheoretical Model is accommodation. Any relational, sexual, social, or emotional desire can be accommodated on the Internet, which could result in a partner being more willing to engage in certain behaviors that express parts of his/her personality that he/ she would otherwise be unwilling to express in one’s face-to-face relationships. An example of this concept is a person engaging in online sexual chatting whereas in their offline relationships, that person would not engage in such behavior (Cooper, Galbreath, & Becker, 2004). Structural Changes and Blurred Boundaries New forms of media usage in relationships have changed the structure of romantic relationships. For example, the relational roles that refer to the rules regarding with whom we share information and how the couple manages the resulting boundary issues can now be shared and compared on social media. Increased social media usage within a couple’s relationship can have a detrimental effect if the couple has not negotiated what information is appropriate to post and what information is to be kept private. Another example of how the rules of interaction with others can be compromised is through cybersex engagement, when one partner gets his/her sexual needs met online without the other partner knowing about it. When couples do not discuss the rules regarding online usage, each partner is left to define what constitutes infidelity. If one partner views the other partner’s online behavior as detrimental to the relationship, tension begins to develop (Daneback, Cooper, & Mansoon, 2005). The use of technology includes not just the social aspects of technology but the use of technology for work, as well. Research has identified an increase in blurred boundaries between work and home life, which can negatively impact couples’ relationships. As telecommunicating becomes more common, separate family time from work time becomes further blurred. A  result of melded work–family boundaries can be increased distress and

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lowered family satisfaction (Chelsey, 2005). Technology can also be used to triangulate the couple themselves. As opposed to directly relating to each other, the couple may use technology to avoid direct communication. Sexual interactions between partners can also be negatively impacted by online behavior. Research has found that heterosexual women tended to be more concerned about their partner’s online sexual activity compared to heterosexual men, and women expressed greater feelings of betrayal regarding their partner’s online sexual activities (Grov et  al., 2011). Similarly, when one partner in a relationship frequents online pornography sites, the other partner oftentimes feels betrayed, disrespected, and less sexually desirable (Bergner & Bridges, 2002). Young, Griffin-Shelley, Cooper, O’Mara, and Buchanan (2000) found that approximately one-third of divorce cases have been related to Internet infidelity. Cybersex and cyber affairs offer a level of excitement that may not be present in the offline relationship. Face-to-face relationships often cannot compete with the instant gratification one can get from new partners online. In addition, face-to-face relationships take longer to develop a sense of intimacy, whereas online relationships can have the appearance of intimacy in a matter of days or weeks (Cooper et al., 2004). These characteristics tend to increase the likelihood of infidelity occurring. At times, a partner’s involvement in technology can supersede the importance of the relationship. The over-involvement in the use of technology often decreases a couple’s level of intimacy. Partners report feeling excluded and that compulsive Internet usage had a deleterious effect on their relationships. It is difficult to determine what amount of technology usage would be considered excessive, since it will vary from person to person. Some signs of technology over-usage would be the development of cognitive and emotional symptoms, such as an increase in loneliness, anxiety, or depression. Though exploring Internet/ technology addictions are outside the scope of this chapter, clinicians should consider using addiction applications in treatment, if appropriate. When a couple spends too much time connecting through technology, there can be an inadvertent decrease in the autonomy of each partner. The expectation of partners to always be available or to respond immediately can hinder an otherwise healthy relationship. Katz and Aakhus (2002) identified the phrase “perpetual contact” to explain this dynamic. Having too much connection with one’s partner can inevitably lead to the demise of the relationship since both individual people become lost or enmeshed in the relationship. Technology can also allow jealous partners to track their partner’s movements. When technology is used by dominating and/or insecure partners, the opportunity to engage in controlling behaviors is increased. This often includes reading a partner’s emails and text messages, reviewing the partner’s web browsing history, and even installing monitoring software (Helper & Whitty, 2010). Given these threats, it is easy to see how technology can have a negative impact on the couple’s relationship, especially if couples

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do not discuss and agree upon their use of technology within their relationship. Part of couples counseling should include an assessment of technology usage in the relationship. Positive Implications of the Use of Technology in a Relationship Obviously, there are many positive uses of technology that can enhance a couple’s relationships. As previously discussed, technology can be used to initiate and develop relationships, and once in a relationship, many couples will turn to the Internet as a way to increase the communication with their partners when they are apart. Couples in a long-distance relationship report an increase in the quality of their relationship when technology is utilized to engage with one another while physically apart. Technology allows for the couple to stay connected, resulting in feelings of closeness (Baker, 2002). Regardless of distance apart, many couples who are busy juggling multiple life tasks rely heavily on technology to stay connected to their partners. Both synchronous and asynchronous forms of communication allow for couples to stay connected, regardless of hectic schedules, and text messaging is another common form of communication (Coyne et al., 2012). Another positive way that couples use the Internet is to gain information about ways to increase sexual intimacy with their partner. According to Grov et  al. (2011), some couples reported greater sexual intimacy after viewing sexual content on the Internet with their partners. This included an increase in the frequency of sexual interactions, a better ability to discuss sexual practices within the relationship, and a willingness to try new activities. Individual Attitudes Toward Internet Infidelity A common presenting issue in couples counseling is infidelity. Infidelity can be described as “the breaking of trust and the keeping of secrets in an intimate partnership” (Schneider, Weiss, & Samenow, 2012, p. 136). According to this broad definition, physical contact is not necessary for the act to be considered infidelity. There are numerous ways in which a person can access an abundance of sexual content on the Internet, whether it be through the use of a webcam, video streaming, computer-based interactive sex, chat rooms, online bulletin boards, sexting, virtual world sex, and porn file transfer sites. The question is, what constitutes infidelity in a relationship when the use of the Internet is involved? For many couples, the question of what defines an online affair does not get addressed until a breach of trust occurs. Many people question whether an affair can exist when no physical contact has happened. However, the emotional reactions from the partner who is hurt are similar to those of a person who did have a partner physically cheat. In a study conducted by Schneider et  al. (2012), 87.5% of survey participants reported negative consequences to their relationship when a partner engaged in cybersex activities. The negative consequences ranged from loss

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of trust to termination of the relationship. Most couples agreed that falling in love, cybersex, flirting, and sharing of personal, intimate details were unacceptable online behaviors. The impact of these breaches of intimacy was no less harmful to the relationship just because the emotion or sexual “encounter” occurred via the Internet. The general viewpoint regarding infidelity is that there is a gender divide when it comes to what is considered unacceptable behavior. There are also different reasons why men and women enter into extramarital relationships. Research demonstrates that women may enter into extramarital affairs because they want a friendship or an emotional relationship in comparison to men, who are more likely to be interested in sexual relationships. Marital satisfaction among heterosexual couples is also shown to have gender differences. When heterosexual couples report problems, women are more likely to identify a lack of affection whereas men are more likely to express sexual concerns (Schneider et al., 2012). Warning Signs of Internet Infidelity and Boundary Violations Young et al. (2000) identified the following warning signs of online infidelity: changes in sleep patterns, increased need for privacy, neglecting of responsibilities, being caught in a lie, changes in personality, decreased sexual desire with partner, and a lack of involvement in the original relationship. Partners who have been cheated on reported an underlying gut feeling that something was going on with their partner. These partners reported a change in their partner’s behavior before or during the time that the infidelity occurred. This change included an increase in the amount of time that the partner was spending on social media sites. Lastly, these partners noticed general changes in behavior, such as closing down computer windows when the partner would enter the room and creating secret passwords. One study exploring the treatment of partners affected by cybersex found that the discovery of sexual and/or romantic betrayal by a long-term partner resulted in trauma for the partner, similar to the trauma experienced after the loss of a loved one, job, or home. The lack of a physical sexual affair was irrelevant to the negative impact left on the partner. The faithful partners reported feeling victimized not only by the sexual affair but by the emotional abuse of having been lied to and repeatedly denied the truth by their partner. Secondary feelings reported by the faithful partner included feelings of anger, fear, self-doubt, pain over the loss of the relationship, shame, selfblame, and depression (Schneider et al., 2012). Assessment Considerations Unfortunately, the numbers of available assessments for evaluating the adverse impact on couple relationships due to social media and technology use is still limited. There are some helpful instruments that can be easily

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used in couples work for assessing the impact of technology on couples and families, including the Ecological Elements Questionnaire (EEQ). The EEQ quantifies an individual’s technology usage and explores the influence of the 7As (identified earlier in this chapter). The Technological Genogram (TG) is a semi-structured interview tool used to identify the dynamics and patterns of technology usage at an individual and intergenerational level (Hertlein, 2012). The downfall of these assessments is that neither of them measures the interaction between an individual’s perception of their technology use and how their technology usage impacts their romantic relationships. A third instrument is the Technology and Intimate Relationship Assessment (TIRA). This assessment is a 47-item pool that includes a demographic and background questionnaire (Campbell & Murray, 2015). Clearly, formalized assessment regarding the impact of technology on relationships continues to be a developing area. However, a couple’s counselor can still verbally assess the couples’ technology usage and its impact on their relationship. Overall, when counseling couples it is important to assess for the positive and negative aspects of the use of technology in the relationship. This requires the counselor to be aware of the different types, uses, and implications of technology and should include a brief assessment of how the couple utilizes technology in their relationship and the couple’s intimate connections and relationship satisfaction. Furthermore, assessing for the client’s access to email, cell phone, Internet websites, chat rooms, etc., will be informative in gaining insight into the scope of the couple’s problem area (Hertlein & Webster, 2008). Case Conceptualization: Individual and Couple Case conceptualization is a process that allows the counselor to identify the presenting concerns of a client within the context of a theoretical framework. This refers to how the counselor explains or understands the client’s presenting symptoms, such as personality characteristics, thoughts, emotions, and behaviors. The conceptualization of a client assists in the development of treatment goals and strategies to utilize within the sessions (Constantine, 2001). Applying an individual case conceptualization to the partner who committed acts of infidelity will provide a framework from which to understand the person’s problematic Internet-related behaviors. This involves taking into context the person’s personality traits and known background information. This process will aid the counselor in identifying effective clinical diagnosis(es) and treatment considerations. The counselor can then develop an individual conceptualization for the non-adulterer partner by understanding the perception of the detrimental impact of the partner’s usage as well as a couple’s conceptualization. In some cases, there will be an underlying problem that is related to the outward behavior of infidelity. When

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reviewing cases involving Internet-related infidelity, it is common to find cybersex usage as a possible symptom of a sex addiction (Schneider et al., 2012), the Internet being used to provide an escape from an unfulfilling relationship (Young et al., 2000), and social skills deficits. Gender and Cultural Considerations Several studies that have been conducted on the use of the Internet for sexual activities have found gender differences. The studies reviewed did not denote the sexual orientation of the participants; rather, participants were simply classified as male or female. More males participated in online sexual activity than females. Differential socialization was identified as one of the possible explanations for this difference. Cooper et al. (2004) stated that women reported preferring more interaction while engaging in online sexual activities in comparison to men, who preferred visual cues. Men and women do not differ in the amount or frequency in which they experience jealousy in their relationships, yet men and women do differ in the types of triggers for jealousy that they experience. One theoretical viewpoint utilizes a social– cognitive lens to explain this gender difference. Harris (2004, p. 65) stated that:

M

en tend to think sexual infidelity would be more distressing because they infer that if a woman has sex with another man, she is probably also in love with him. Women tend to believe that men can have sex without being in love. Hence, sexual infidelity does not necessarily imply emotional infidelity.

Research conducted by Helper and Whitty (2010) also found similar evidence to support that more women experience emotional betrayal as a form of infidelity than men. In these studies, most women reported that they would end a relationship if they found out that their partner was engaging in an online affair. A greater number of women than men also reported that online sexual activity was a severe betrayal in a relationship. Aside from the issue of gender differences, there is also the concern for what is considered appropriate sexual behavior, as sexuality is constructed within one’s cultural upbringing. It is critical to understand the cultural viewpoint that individuals and couples bring to their relationships, since each person’s view of acceptable/unacceptable behavior is housed within that cultural unit. Previous sexual practices once considered unacceptable have now changed as our boundaries for what is private versus public information have significantly changed over the last 20  years. Thus, couple counselors need to routinely include an exploration of culture, gender, SES, and sexual orientation factors in their conceptualization and treatment approaches of the couples with whom they work.

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Treatment Considerations for Internet Infidelity When working with couples who have experienced Internet infidelity, counselors are faced with multiple clinical issues. Hertlein (2012) identified seven therapeutic tasks when working with a couple that has experienced Internet infidelity: (1) the development of physical boundaries, including identifying limits to the usage of the computer, restriction on web pages visited, and the presence of the partner while using the computer; (2) the development of psychological boundaries, which refers to the validation and normalization of the betrayed partner’s feelings, acknowledgment of the sexual and/ or emotional nature of the affair, and a discussion of the unfaithful events that occurred; (3) holding the partner who cheated accountable for his/ her actions, the violation of the trust of the relationship, and the feelings of the betrayed partner. This involved the importance of the cheating partner understanding the feelings of betrayal and how the relationship was negatively impacted by the infidelity; (4) developing an awareness regarding the etiology of the problem. Most of the participants in the study agreed that Internet infidelity was a symptom of a larger issue. In order to adequately treat the couple, the root issue must be identified and resolved; (5) assessing the couple’s context and readiness for change, which includes exploring the couple’s negotiation skills, level of enjoyment, kind of relationship they had prior to the infidelity, and enjoyable activities that they used to do together; (6) assessing the presence of unique circumstances, which involves determining whether the behavior was related to some form of an addiction, determining if there are physical issues involved in the problem, evaluating gender expectations, and if/how they may have been a part of the relationship; and, lastly, (7) Hertlein (2012) suggests that couples work toward forgiveness, which begins with the partner who engaged in online infidelity taking responsibility for their actions and then discussing communication between the couple. The counselor should assess the couple’s willingness to move toward forgiveness. Further education on the difference between forgiving and forgetting and describing forgiveness as a decision is part of this step. Olson, Russel, Higgins-Kessler, and Miller (2002) identified a three-stage process describing what a partner experiences after infidelity is discovered. The first stage is equivalent to an emotional roller coaster. It is characterized by sadness, anger, hurt, and feelings of betrayal. In order for participants to move to the second stage, they must experience a decrease in emotional reactivity and begin to develop a meaning-making of the event. The counselor is expected to assist the betrayed partner with learning how to identify and express their emotions. Hertlein (2012) identified the importance of assisting the couple in defining the affair. For couples who disagree on the definition of infidelity, the counselor will need to help them discuss appropriate Internet behaviors and reevaluate the definition of infidelity, focusing on online

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behaviors. It is important that the counselor allows the couple to determine whether something was infidelity rather than the counselor imposing his or her own definitions on the client/couple (Helper & Whitty, 2010). During this stage, the counselor can assist with identifying the warning signs and the contextual and relational factors that led up to the infidelity. This can assist with the meaning-making process. The counselor can help the couple learn how to discuss the affair together. Furthermore, the counselor will assist the couple in establishing new boundaries for the relationship in regards to monitoring online behavior. Since the trust of the relationship was destroyed, the couple must learn how to repair that trust. However, it now becomes a matter of developing trust again by the faithful partner rather than trust being automatically restored to the unfaithful partner (Olson et al., 2002). Aspects of this model can be broadened beyond work with couples where infidelity is an issue. Any threat to emotional intimacy, such as constant phone/computer use, that serves as a barrier to emotional connection can be viewed through this model’s lens. It is important for the counselor to assist the couple in learning healthy ways to integrate technology into their relationship, especially since technology is nearly unavoidable in today’s society. Healthy ways to integrate technology can include experimenting with using email to write out one’s thoughts and feelings regarding topics that are hard for the couple to discuss face-to-face (Hertlein, 2012). In the end, the couple will need to determine the parameters that will be placed around technology usage in the relationship. Case Example: Mike and Emily Mike (29  years old, Caucasian, Irish-American) and Emily (29  years old, Caucasian, Polish-Irish American) have been living together for four years and dating for the past five years. They have one son together, Kyle (3 years old). Mike and Emily have come to counseling in order to work on their relationship since Emily found evidence of Mike communicating online and sexting with another woman. Mike stated that he never intended for this online acquaintance to take on the life that it did, feeling at times as though he was in over his head, yet unable to stop. Emily discovered the relationship after she accidently grabbed Mike’s phone one evening, thinking it was her phone. When she opened up the text messaging feature, she noticed a picture of a half-naked woman, which prompted her to open the thread, reading all of the previous communications sent. Emily was in complete shock at what she found and did not know how to handle it. She did not confront Mike right away and instead continued to look through his phone when he would leave the room, checking his email and Facebook and monitoring his spending and travel. Finally, after about a month of monitoring Mike’s behavior, Emily confronted Mike. At first, he denied the claims but eventually had to

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own up to what Emily was saying due to the confirming evidence that she had on him. Individual Conceptualization: Mike Mike explained that about six months ago he started connecting with some old friends on Facebook, and a female acquaintance made a comment about a photo he had posted, leading to some exchanges on the site. Before he knew it, he and this woman were sending messages through the site’s messenger feature. These messages allowed him the privacy of sharing personal information without others being able to see it. He stated that messages started off innocently, sharing information about each other’s lives, such as work and family. Soon after, the woman started flirting with him. He reported feeling excited by her attention, a feeling that had been missing from his life for the past year or so. When he was communicating with her, he was able to forget about his stress and felt like he was a different person. As the flirting progressed, Mike started to receive pictures from her. The pictures were innocent to begin with and slowly became more provocative. Mike responded with sending pictures of his own to her, which eventually led to them engaging in cybersex. Individual Conceptualization: Emily Emily reported feeling drained by the end of the day and not having any energy to give to her relationship with Mike. Her days were consumed with work and taking care of their son, which led to her and Mike having less sex than they used to. This became a source of tension in their relationship. Emily felt misunderstood and resentful at times toward Mike because the burden of the child rearing responsibilities fell mainly on her. She stated that she knew their relationship was not going very well but thought it was just a normal slump and that it would get better as their son became older. Couple Conceptualization Mike and Emily were stretched between family life, work, and financial responsibilities. Their schedules left little time for each other, so Mike sought out the Internet, specifically social networking sites and online browsing, as a way to unwind. Emily explained that she started noticing changes in Mike’s behavior about three months prior to discovering the infidelity, including him changing the passwords on his phone and social networking sites, spending more time on his phone, and seeming overall distant from her. Both reported that their home atmosphere was tense and uncomfortable. Assessment Considerations I began my assessment of this couple by obtaining a background on them individually and then as a couple. I assessed how long they had been together,

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what their relationship was like before the Internet affair took place, and how they had been working through the affair up to this point. In addition, I explored the couple’s level of emotional intimacy, as this is an important aspect of the relationship that may signal part of the core issues going on prior to the infidelity. At this time, Mike reported that he had discontinued contact with the other woman. He stated that he had never done anything like this before and did not want to end his relationship with Emily. Mike disagreed with Emily’s idea that he was unfaithful, since he never met the woman in person and only exchanged pictures. Emily reported feeling betrayed and struggling with thoughts of the emotionally intimate moments he shared with another woman. The couple is now trying to repair the damage that has been done to their relationship as a result of Mike’s online behavior. Treatment Considerations Treatment will begin with the development of boundaries around the use of social networking sites in the home. This is important, because Emily feels the most insecure knowing that Mike still has a Facebook account. She and Mike will need to work on specifying boundaries around what is acceptable/ unacceptable use of technology in their relationship. Since Mike does not view his past behavior as infidelity, it will be necessary for the couple to first address this issue. This will involve identifying ways to acknowledge each partner’s point of view and eventually coming to an agreed-upon understanding of what happened. It is essential that Emily receives validation of her feelings of betrayal regarding her perception of a sexual and emotional affair occurring between Mike and the other woman. I will assist the couple in learning ways to effectively express their thoughts and emotions. Mike will also work on continuing to acknowledge his indiscretions, enabling him to take responsibility for his actions. This includes understanding the ways in which his relationship was damaged by his actions. I will also work with the couple on understanding the etiology of the infidelity. In order to repair the relationship, both parties must first understand where things began to change in their relationship and how these changes assisted in the emotional distancing from one another. This process will involve a history taking of their past relationships to determine if there is a pattern of emotional distancing. Since the couple came to counseling with a desire to repair their relationship, I will reassess the couple’s readiness for change and ability to move forward in the repair process. I will assist the couple in learning healthy ways to communicate with each other and identifying pleasant activities that they can do as a couple and as a family. The final phase of treatment will focus on how to move forward after the affair, with an emphasis on forgiveness. This is an important step in the repairing of the relationship since it allows the

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couple to acknowledge the damage that has occurred and move forward with a resolution to heal the relationship. Clinical Outcome The couple continued to work on repairing the trust in their relationship and identifying ways to increase their emotional connectedness. Mike shared his electronic passwords, allowing Emily to check his status at any time. The couple learned healthy communication patterns and started allocating time for date nights. Even though their schedules remained hectic, the couple learned ways to ask for what they needed/wanted from one another instead of withdrawing from the relationship when times were stressful. Conclusion Technology offers an abundance of opportunities to create new relationships, connect with distant friends/family members, and to be connected to a world otherwise outside of their immediate area. This has required couples to learn how to navigate the use of social media and technology in their relationships. When working with couples faced with Internet-infidelity related problems, counselors will be expected to complete a full assessment, identifying how the couple uses technology and the ways in which the relationship has been negatively impacted by its use. Treatment recommendations include assisting the couple in exploring the emotional damage to the relationship, identifying ways to repair trust, developing healthy communication patterns, building parameters around the use of technology, and learning how to engage in the act of forgiveness in order to move forward. References Baker, A. (2002). What makes an online relationship successful? Clues from couples who met in cyberspace. Cyberpsychology  & Behavior, 5, 363–375. doi:10.109/109493102760275617 Bergner, R., & Bridges, A. (2002). The significance of heavy pornography involvement for romantic partners: Research and clinical implications. Journal of Sex and Marital Therapy, 28, 198–206. Chelsey, N. (2005). Blurring boundaries: Linking technology use, spillover, individual distress, and family satisfaction. Journal of Marriage and Family, 67, 1237–1248. Constantine, M. G. (2001). Multicultural training, theoretical orientation, empathy, and multicultural case conceptualization ability in counselors. Journal of Mental Health Counseling, 23(4). Cooper, A., Galbreath, N., & Becker, M. (2004). Sex on the Internet: Furthering our understanding of men with online sexual problems. Psychology of Addictive Behavior, 18, 223–230. Coyne, S. M., Busby, D., Bushman, B. J., Gentile, D. A., Ridge, R., & Stockdale, L. (2012). Gaming in the game of love: Effects of video games on conflict in couples. Family Relations, 61(3), 388–396. doi:10.1111/j/1741-3729.2012.00712.x

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Daneback, K., Cooper, A., & Mansoon, S. (2005). An Internet study of cybersex participants. Archives of Sexual Behavior, 34, 321–328. doi:10.1007/s10508-1000513120-z Grov, C., Gillespie, B., Royce, T., & Lever, J. (2011). Perceived consequences of casual online sexual activities on heterosexual relationships: A U.S. online survey. Archives of Sexual Behavior, 40, 429–439. Harris, C. R. (2004). The evolution of jealousy: Did men and women, facing different selective pressures, evolve different “brands” of jealousy? Recent evidence suggests not. American Scientist, 92, 62–71. Helper, E. J., & Whitty, M. T. (2010). Netiquette within married couples: Agreement about acceptable online behavior and surveillance between partners. Computers in Human Behavior, 26, 916–926. doi:10.1016/j.chb.2019.02.006 Hertlein, K. M. (2012). Digital dwelling: Technology in couple and family relationships. Interdisciplinary Journal of Applied Family Studies, 61, 374–387. doi:10.1111/ j.1741-3729.2012.00702.x Hertlein, K. M.,  & Webster, M. (2008). Technology, relationships, and problems: A  research synthesis. Journal of Marital and Family Therapy, 32, 445–460. doi:10.1111/j.1752-0606.200.0007.x Katz, J. E., & Aakhus, M. A. (2002). Introduction: Framing the issues. In J. Katz & M. Aakhus (Eds.), Perpetual contact: Mobile communication, private talk, public performance (pp. 1–14). Cambridge: Cambridge University Press. Kerkof, P., Finkenauer, C., & Muusses, L. D. (2011). Relational consequences of compulsive Internet Use: A longitudinal study among newlyweds. Human Communication Research, 37, 147–173. doi:10.1111/j.146-295.2010.01397.x Olson, M. M., Russel, C. S., Higgins-Kessler, M., & Miller, R. B. (2002). Emotional processes following disclosure of an extramarital affair. Journal of Marital and Family Therapy, 28, 423–434. doi:10.1111/j.1752-0606.2002.tb00367.x Schneider, J. P., Weiss, R., & Samenow, C. (2012). Is it really cheating? Understanding the emotional reactions and clinical treatment of spouses and partners affected by cybersex infidelity. Sexual Addiction & Compulsivity, 19, 123–139. doi:10.108 0/10720162.2012.658344 Spears, R., & Lea, M. (1994). The hidden power in computer-mediated communication. Communication Research, 21, 427–459. doi:10.1177/009365094021004001 Young, K. S., Griffin-Shelley, E., Cooper, A., O’Mara, J.,  & Buchanan, J. (2000). Online infidelity: A  new connection in couple relationships with implications for evaluation and treatment. Sexual Addictions and Compulsivity, 7, 59–74. doi:10.1080/10720160008400207.

3 ASSESSMENT, DIAGNOSIS, AND CASE CONCEPTUALIZATION WITH COUPLES Len Sperry

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orking with couples in a therapeutic context is almost always challenging, and e usually quite gratifying. What makes it particularly challenging is that an increasing number of couples are disordered couples. This means that one or both partners can be diagnosed with a symptom disorder or a personality disorder, or that a relationship disorder is present. This chapter provides necessary background material for the chapters that follow. It focuses on three areas. The first is the assessment of the couple: presenting problems, relational history, and relational pattern. The second area involves diagnosis of partners and the overall relationship. Included are an introduction to DSM-5 mental disorders as well as relationship disorders. The third area describes individual case conceptualization and couple case conceptualization. Finally, a case example illustrates all of these considerations. Assessment This section focuses on the assessment process in couple therapy. Key elements of this assessment are: assessment of the couple’s presenting problems, their relational history, relational dynamics, cultural dynamics, relational patterns, couple strengths, and their expectations for therapy, as well as their explanations of presenting concerns. Such a couple assessment and DSM-5 diagnoses, if involved, are the basis for developing a couple case conceptualization. Relational History Assessment usually begins with the history of the couple’s relationship from initial attraction to the present. From there, families of origin information

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of the partners is elicited. The genogram can be particularly enlightening. Then, the assessment focuses on important system factors such as boundaries, power, and intimacy, as well as sexual issues, money issues, and level of social interest and cooperation. Eliciting the relationship history of begins with questions such as: how did you meet? What attracted you to each other? How did your dating go? How did you decide to formalize your relationship (marriage)? How did things go when you were first married? How have things changed since then? Exploration of the couple’s history in relation to their families of origin can be very useful. It can explicate issues and bringing them into the therapy process. The genogram is a powerful tool for both understanding the influence of a couple’s families of origin and providing feedback to the client about these dynamics. It is a simple, graphic way to trace the multigenerational influences on an individual or family’s present-day functioning. It can easily highlight relational patterns that repeat themselves, particularly with regard to unresolved emotional issues. They can trace addiction history, patterns of divorce, abuse, and diseases within the family of origin. Additional information about influential life events, significant deaths in the family, and coalitions in the family of origin, which may be difficult to directly assess in an interview, are readily discussed in a genogram (McGoldrick, Gerson, & Petry, 2008). Typically, couple therapists construct a genogram of one partner and encourage the other partner to fill in information and make comments. Then the process is reversed Relational Dynamics Another important area of assessment is relational dynamics. This involves boundaries, power, and intimacy. To elicit information on structure or boundaries, ask questions like: who else is considered to be part of the couple’s system? What is being excluded from the couple’s relationship and assigned to children or others? Who and what events or things are intruding into the couple’s relationship? For power, the therapist asks: who is in charge? How do partners deal with power in their relationship? For intimacy, some questions are: how near, how far, and how do the partners tolerate or respond to each other’s needs and desires for intimate contact and closeness? How do partners use emotional and geographical distance when struggling with their need for closeness? Answers to such questions provide significant data for the therapist in assessing the couple’s system. Cultural Dynamics Assessment of a couple wherein one or both partners are from a different culture is also essential. It is important to include questions about the presenting problem and how the couple views the problem from their unique cultural perspective. Ask both partners about their roles within the home

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and within their family. Inquire about the role of each partner’s family of origin, as influenced by their cultural norms. Other areas of assessment with culturally diverse couples include a wide range of norms for the marriage relationship. The therapist should also inquire about issues such as the usual age for men and women to marry within the partner’s diversity group, expectations regarding husband/wife prior to and after marriage, and the basis for mate selection. Finally, inquire about each partner’s understanding of their sexual relationship and expectations for interaction with outsiders, including in-laws and extended family members (Bhugra & De Silva, 2000). Couple Strengths and Resources Now that history and dynamics have uncovered the couple’s problem and issues, it is important to identify the strengths and resources that the couple possesses to deal with these problems and issues. This part of the assessment is crucial for tailoring treatment to the strengths of each partner and to the couple as a whole. Accordingly, the therapist would do well to assess the level of support, appropriate role models, emotional energy, and cognitive ability to make the kind of changes that are necessary. It is also important to identify the couple’s past successes and failures and each partner’s sense of personal responsibility for the condition of the relationship. In addition, partners’ level of readiness for change, resistance to treatment, and expectations for therapy are elicited. Treatment Expectations Effective therapists attend to the expectations that couples have for therapy. Recent research on couples’ expectations demonstrates the following. Couples expect to discuss problems, the events that led up to their problems’ development, and the ways in which those problems impacted individual and couple functioning (Tambling  & Johnson, 2010). They also expect to recover from their problems (Froude & Tambling, 2014). Accordingly, begin this inquiry by asking about what each partner expects from therapy. Explanatory Model Understanding a couple’s explanation of their presenting problems is important because it provides the therapist with a client-focused context of how to approach discussions about the problems during the course of treatment (Froude & Tambling, 2014). These client explanations are referred to as the client’s case conceptualization, in contrast to the therapist’s expectation (Sperry, 2010a). Research on couples’ explanations of their problems has clinical value for therapists. Understanding a couple’s explanations provides the therapist with a client-centered context on how to approach discussions about the problems during the course of treatment. Furthermore, it suggests

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that couples explain their problems from an individualistic standpoint and they tend to internalize problems (Froude & Tambling, 2014). Explanation or explanatory model is the client’s theory or best guess for what is causing their presenting problems, or personal or relational issues. It is akin to the therapist’s case conceptualization (Sperry, 2010a). Trainees are often surprised to learn that clients have come up with their own case conceptualizations. Because clients are often aware of their conceptualization, therapists need to understand it since the more it differs from the therapist’s conceptualization, the more likely treatment will be negatively impacted. This can be manifested in many ways: tardiness or no-shows for appointment, failure to do homework; or even premature termination. Accordingly, the therapist would do well to elicit the client’s explanatory model, particularly since it often reflects their expectations for treatment. Then, after eliciting the client’s explanatory model and sharing the therapist’s case conceptualization, a mutually agreeable conceptualization can be negotiated (Sperry, 2010b). Individual Dynamics and Systems Dynamics When working with couples, effective therapists focus on both individual and systems dynamics. A  basic premise is that each partner’s behavior reflects their personal maladaptive pattern (Sperry, 2010b). A second premise is that, irrespective of whether the client reports an individual symptom or a relational issue, it is embedded in the couple’s systems dynamics, and that the symptom or issue serves to maintain the homeostasis or sense of normalcy of the system (Gehart, 2010). Assessment of Systemic Dynamics and Patterns Virtually all couple therapy approaches involve the assessment of system dynamics, particularly “relational interaction patterns” within the system (Gehart, 2017). Assessing this pattern involves identifying the problematic interaction pattern underlying the presenting problem. Usually, couples have one or two such patterns that are reflected in their presenting problem. The therapist traces such patterns by noting one partner’s emotional and behavioral response and then the other partner’s response until a sense of normalcy returns. “Neither partner sees the mutually reinforcing pattern, nor if they do, it is seen as ‘caused’ by the other” (Gehart, 2017, p. 257). Assessment of such interaction patterns, along with the identification of each partner’s own maladaptive pattern, is central to developing a couple case conceptualization and planning effective interventions. Relational Interaction Patterns Each partner plays a role in their relationship, as each displays one or two habitual and cyclical patterns of relating with which each has learned over

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time to cope. In the couple therapy literature, these patterns are referred to as a couple’s interaction patterns or relational patterns. None of the negative patterns described below result in both partners growing and thriving. At best, they allow the relationship to survive, at least for a while. Presumably, couple therapy can break and replace these patterns with more ­adaptive ones. Here are brief descriptions of five of the most common negative relational patterns and one positive pattern. Demand/Withdraw This pattern occurs when one partner blames, accrues, criticizes, or demands [demand] change from the other partner. In response, the other partner gives in, defers, surrenders, or complies [submit] (Christensen  & Shenk, 1991). This pattern is also referred to as the pursuer–distancer, engulfment– abandonment, closeness–distance, or affiliation–independence pattern (Christensen  & Shenk, 1991). It is the most common relational pattern among couples and also the most researched. It is an indicator of negative emotion, partner hostility and aggression, relationship dissatisfaction, and divorce. Recently, it has been studied as a predictor of depression (KnoblochFedders et al., 2014; Holley, Haase, Chui, & Bloch, 2018). Other negative relational patterns are variants of this one. Demand/Submit This pattern occurs when one partner blames, accrues, criticizes, or demands [demand] change from the other partner. In response, the other partner avoids, fails to respond, is defensive or silent, or essentially refuses to discuss the concern [submit]. While this is a relatively common interaction pattern, it has not received as much research attention as the demand/withdraw pattern (Knobloch-Fedders et al., 2014). Withdraw/Withdraw This pattern occurs after a couple has exhausted the demand/withdraw pattern. Both partners are hesitant to engage emotionally and, in the face of conflict, both withdraw further. They feel hopeless over their situation and begin to give up. In these cases, the pursuer may be a “soft” pursuer who is hard to recognize because he or she does not show the overwhelming anxious energy seen in a lot of pursuers and who, despite being a pursuer, gives up easily. The other possibility, which is more common, involves a “burnt out” pursuer who has now given up reaching for the other partner. Withdrawal then can be the beginning of grieving and detaching from the relationship (Kasting, 2015).

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Attack/Attack This pattern involves a sequence in which an attack is responded to with an attack. Not surprisingly, this pattern results in an escalation of relational discord. The escalations are a variant of the demand/withdraw pattern. In response to the demanding partner [attack], the withdrawing partner becomes sufficiently provoked and erupts in anger [attack]. Following the fight, the withdrawer is likely to revert back to the withdrawing role until he or she feels sufficiently provoked again. This pattern is also referred to as the “high conflict couple” (Fruzzetti, 2006). Reactive Demand/Withdraw This pattern occurs when a couple reverses a previous long-standing pattern. This occurs with a role change in one of the partners. For example, a demanding wife [demand] gradually gives up and limits her investment in the relationship. Increasingly, she withdraws and distances herself [withdraw]. Typically, her work-obsessed partner fails to notice this change. She may even leave the relationship. In this reactive pattern, the husband will frantically pursue the wife to prevent a separation. The withdrawing wife refuses to commit to the relationship. Then, the withdrawer takes on the demand role and aggressively pursues his wife. In short, this is a reversal of their previous long-standing pattern of her demanding and his withdrawing. Constructive Engagement This pattern occurs when partners can express issues that bother them in a “non-attacking way that accurately reflects what they feel, think, or want, including accurate expression of primary emotions. The other partner listens, bring curiosity, tries to understand, and communicates understanding, even if he or she disagrees” (Fruzzetti & Payne, 2015, p. 609). This pattern fosters not only problem solving but also validation. This pattern requires that both partners are aware of their emotions and wants and are able to effectively regulate their emotions. Other Ways of Characterizing Couple Interaction Based on her extensive clinical experience, Sue Johnson describes three negative patterns of communication that keep couples stuck. She refers to them as three types of “Demon Dialogues” in a popular book designed for couple therapists to assign couples to read. Each creates communication patterns that are roadblocks to healthy relating. She notes that they occur when couples are unable to safely connect with each other. Each of the dialogues

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match the demand/withdraw, withdraw/withdraw, and the attack/attack patterns (Johnson, 2008). Based on his extensive research with couples, John Gottman has developed a somewhat different way of categorizing intimate relations. Rather than specifying cyclical relational patterns, he has developed at typology based on their relational behavior. Five types are specified: Conflict–Avoiding, Validating, Volatile, Hostile, and Hostile–Detached (Gottman, 2014). The Validating type is positive and predictably results in relational satisfaction and growth, while the other four types do not. Diagnosis This section builds on the Assessment section and sets the stage for the next section on couple case conceptualization. It begins with the role of diagnosis in light of the systemic perspective. Then it describes DSM-5 mental disorders, which are delineated as either symptom disorders, e.g., depression, or as personality disorders. The link between these disorders and relational patterns and couples’ conflict are emphasized. The DSM-5 V-code for relational distress is also described. Finally, the use of standardized diagnostic inventories in identifying and confirming a DSM diagnosis is briefly discussed. Diagnosis and Systems Historically, couple therapists have not relied much on the clinical symptoms and diagnosis of an individual partner in understanding and conceptualizing couple dynamics. Nevertheless, such symptoms tend to be viewed as part of the couple dynamics. For instance, “one partner’s depression may elicit caretaking behavior from the other, creating a strong bond and a sense of meaning for one and sense of being valued for the other” (Gehart, 2017, pp. 259–260). From a systems perspective, therapists would be mindful about the function of clinical symptoms as well as the relational effect of alleviating them since it is not uncommon for the reduction of clinical symptoms in one partner to lead to the emergence of new symptoms in the other partner. Accordingly, when such a pattern is observed, the therapist can focus more directly on rebalancing the couple relationship, which usually resolves the symptoms. When working with couples, effective therapists assume that irrespective of whether an individual symptom or a relational issue is reported, that symptom or issue “is embedded in the larger system and that the symptom maintains the system’s homeostasis or sense of normalcy” (Gehart, 2010, p. 26). Because of the current state of reimbursement, therapists providing couple therapy tend to rely on DSM-5 codes for mental disorders in one or both partners. Typically, these include symptom disorders, as well as personality disorders. Coding of these individual disorders is necessary for the

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authorization and payment of therapy services, since few third-party payers reimburse for relational problems. Many couple therapists tend to rely on systems thinking and, therefore, perform assessment and treatment using only its concepts. For an increasing number of couples, however, one or both partners have serious psychopathology. When this is the case, systems thinking alone does not provide the understanding needed to produce effective treatment. This book discusses the disordered couple and offers alternate methods of viewing, assessing, diagnosing, and tailoring treatment. Specifically, the one presented in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) (American Psychiatric Association, 2013) is discussed in this chapter. Relational Disorders—Individual Disorder Categories Increasingly, couple therapists are accepting classification systems that focus on both individual dynamics and relationship dynamics. In DSM-5, these have specific diagnostic labels and codes, including those identified as relationship disorders. Reiss (1996) identifies four broad categories for understanding and classifying individual disorders and relationship disorders. In particular, trainees find these categories helpful in understanding the interaction between individual and couples dynamics and psychopathology. 1.  Relationship Disorders Only In addressing disorders in this category, the couple therapist focuses primarily on relational disorders. For example, Relationship Distress With Spouse or Intimate Partner (V61.10) or Spouse or Partner Abuse (995.82). 2.  Relationship Disorders That Are Associated With Individual Disorders For disorders of this category, the relationship is still the primary focus of treatment. Part of the reason for treating the relational problem is that it is likely that this problem evokes or influences a more serious problem in one of the individual couple members. This level of analysis is used when both relationship and individual disorders are detected. For example, Relationship Distress With Spouse or Intimate Partner (V61.10) and Borderline Personality Disorder (301.83). 3.  Individual Disorders That Have Little or No Relational Impact In this category, an individual disorder is central in the presenting problem. For example, the onset of another episode of Major Depressive Disorder (296.33) in one partner who has carried this diagnosis for years, but has been effectively controlled with a brief hospitalization and medication, and this disorder has limited or no effect on the relationship.

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4. Individual Disorders That Are Strongly Influenced by Relationship Factors In this category, the individual disorder is the primary and continuing focus of attention, but additional treatment is needed for the couple in order to promote a rapid and full recovery. For example, the onset of the manic phase of bipolar I disorder (296.42) in one partner engenders considerable distress in the other partner for a several days until the phase runs its course and the distress resolves. Value of DSM-5 Diagnosis in Couple Therapy DSM-5 is a diagnostic system. It is a compendium of both mental disorders and relationship disorders. Mental disorders are specified as symptom disorders, such as depressive and anxiety disorders, or as personality disorders. While DSM can be invaluable for diagnosis, there are definite limitations when it comes to advice on treatment selection and implementation. In other words, a DSM-5 diagnosis is only the initial step in the comprehensive treatment planning process. Thus, additional information is necessary to plan and select relevant treatment, and this is especially true for couple therapists. Nevertheless, couple therapists need to be aware of the DSM-5 and the importance of diagnosis. It is time that therapists recognize that the merits of diagnosis outweigh any concerns they have about the role of diagnosis in working with couples and families. For example, diagnosis is particularly helpful in the recognition and assessment of a partner’s potential for suicide, homicide, or other self-destructive behavior. The reality is that individuals with Major Depressive Disorder, Borderline Personality Disorder, and alcohol or substance use disorders are at a particularly high risk for these self-destructive behaviors. Similarly, individuals in a manic state must be promptly and accurately identified, since they can do considerable damage to themselves and their partners with inappropriate, uncontrolled behaviors such as wild spending or promiscuity. I believe that couple therapists should have a thorough knowledge of individual psychopathology and diagnosis, since the pathology of one or both partners can greatly affect couple functioning and well-being. With a working knowledge of the DSM-5 criteria, therapists can preliminarily assess the nature and severity of individual issues—chronic anxiety and mood disorders, thought disorders, and personality disorders—as well as the influence of personality traits on relational functioning. Such knowledge of diagnosis can also increase the likelihood that couple therapists will work within the limits of their training and experience and presumably make better decisions about appropriate referrals when indicated. It is also my opinion that understanding the information provided by the DSM-5 can help the therapist to better understand just what is occurring in a couple system, rather than just in an individual. This knowledge can be invaluable in treatment planning.

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Symptom Disorders in Partners Either deliberately or unconsciously, individuals choose intimate partners similar to  themselves, including mental disorders like depression, Bipolar Disorder, autism, and Schizophrenia. When I have asked therapists-in-training if they agree with this assertion, most say no. Until recently, there was little research support for it. Previous studies indicated that it could be the case, but there was no solid evidence because research focused largely focused psychiatric symptoms rather than clinical diagnoses, and reported studies involved small numbers, self-report, or second-hand accounts of partners. That all changed with a recently reported epidemiological study that fully supported this assertion (Nordsletten et al., 2016). In that study, researchers analyzed the records of 700,000 individuals who had been diagnosed with 11 different symptom disorders: Agoraphobia, Anorexia, Anxiety, AttentionDeficit/Hyperactivity Disorder, Autism Spectrum Disorder, Bipolar Disorder, Depression, Obsessive–Compulsive Disorder, Schizophrenia, Social Phobia, or Substance Abuse. Evaluated were how often these diagnoses correlated with that individual’s partner being diagnosed with either the same or a different symptom disorder. The results of this major study were that individuals with symptom disorders were two to three times more likely than the general population to have an intimate partner with a symptom disorder. Some disorders showed a greater likelihood of both partners having the same diagnosis. For instance, individuals with Attention-Deficit/Hyperactivity Disorder or Schizophrenia were seven times more likely to be in an intimate relationship with someone with their same disorder than the general population. With autism, it was over ten times higher (Nordsletten et al., 2016). Symptom Disorders and Relational Patterns In the past decade, researchers have been interested in whether certain symptom disorders may predispose couples to engage in particular relational patterns, or whether such patterns might trigger particular symptom disorders. So far, some studies on anxiety disorders have been reported, but the majority have involved depression and one particular relational pattern: demand/ withdraw. Since depression is the most commonly diagnosed symptom disorder and the demand/withdraw is the most common negative relational pattern, this line of research can have significant clinical value to therapists practicing couple therapy. As noted in a previous section, the demand/withdraw pattern is a detrimental set of communication behaviors in which one partner demands, nags, or criticizes while the other partner avoids or withdraws. Previous studies evaluating the influence of depression on this pattern have shown mixed findings (Papp, Kouros,  & Cummings, 2009; Knobloch-Fedders et al., 2014). One of these studies indicated that the husband demand/wife

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withdraw pattern as well as the wife demand/husband withdraw pattern occurred in the home at equal frequency. Both patterns were more likely to be activated when discussing topics that concerned their relationship. For both patterns, the pattern was most likely to be initiated by the partner in the demander role. Accounting for marital satisfaction, both demand/withdraw patterns predicted negative emotions and tactics during couple interactions and lower levels of conflict resolution. Of particular noted is that partner depression was more common in the partner in the withdraw role (Papp et  al., 2009). This finding was common among most reported studies. A recent study presented the most convincing evidence to date for the link between depression and the demand/withdraw pattern. Results indicated an association between one partner’s level of depression and his or her tendency to withdraw in response to the other partner’s demands. In other words, the more the demanding partner had difficulties in emotion regulation, the more the other partner withdrew (Holley et al., 2018). One clinical implication is obvious: reducing emotion dysregulation in such couples is an essential part of the treatment plan and process. Personality Disorders in Partners The reality is that personality pathology is a common presentation in both individual therapy and couple therapy. The estimated overall prevalence rate for any personality disorder is 9.1% in the general population and up to 40% in clinical settings (American Psychiatric Association, 2013). Clients with personality disorders in individual therapy are a challenge for most therapists, especially those in training or recently licensed. Effectively dealing with long-standing and pervasive patterns of distorted thinking, dysregulated emotions, and maladaptive behavior requires specialized training, supervision, and experience. Such individuals also present unique challenges in couple therapy. Emerging therapists may feel daunted when taking on such a case, given their limited training, experience, and the therapeutic resources available to guide them. Since many of the strategies and techniques of couple therapy are borrowed from the general practice of family therapy, translating these to personality disordered couples requires a level of understanding and skill that novice therapists may not yet possess. Furthermore, the treatment focus in the couple therapy practice tends to be situation-based rather than personality-based. That means that therapists are likely to be more familiar working with couples facing a divorce, infidelity, an illness, or other crisis, rather a long-standing personality pattern escalated to the level of crisis. These are precisely the issues in providing therapy with personality disordered couples (Landucci & Foley, 2014). Some other unique challenges are encountered in working with these couples. Because couples in which there is significant personality pathology

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in one or both partners are increasingly encountered in couple therapy, the need for specialized training and supervision is no longer optional. For instance, forming an effective therapeutic alliance is particularly challenging when the partner is not aware or convinced that he or she is contributing to the presenting problem, and may be complicated by difficulty establishing a trusting relationship with another. Because maladaptive personality patterns are thought to develop from traumatic experiences in childhood or family-of-origin issues, these patterns are engrained through years of repetition by the time the adult presents for treatment. Addressing the inflexible and rigid nature of maladaptive personality pattern requires considerable skill on the part of the therapist as well as much patience, If treating a client with a personality disorder in individual therapy provokes anxiety or negative countertransference in the therapist, treating a couple in which both individuals struggle with personality disorders can be even more intimidating (Landucci & Foley, 2014). DSM-5 and Personality Disorders The idea that maladaptive personality patterns affect marital dissatisfaction is not new. Multiple studies have examined the relationship between personality disorders and relational dysfunction or relationship satisfaction. The level of discord in intimate relationships is higher in young adults with diagnosed personality disorders than those without such a diagnosis. There is also evidence that individuals with personality disorders experience greater interpartner violence in their romantic relationships (Landucci & Foley, 2014). In DSM-5, the personality disorders are grouped into three clusters based on similarities. Cluster A includes the Paranoid, Schizoid, and Schizotypal Personality Disorders. Those with these disorders appear odd or eccentric. Cluster B includes Antisocial, Borderline, Histrionic, and Narcissistic Personality Disorders. These individuals appear dramatic, emotional, or erratic. Cluster C includes Avoidant, Dependent, and Obsessive–Compulsive Personality Disorders. Such individual appear anxious or fearful (American Psychiatric Association, 2013). Research on the impact of personality disorders on relational functioning is quite revealing. For example, individuals with Cluster B pathology demonstrated the greatest sustained amount of relational conflict over a ten-year follow-up period from age 17 to age 27. In contrast, Cluster A or C pathology is related to increased conflict only until age 23, at which point the amount of discord declined to match those without personality disorders. Personalitydisordered individuals are more likely to be involved in relationships marked by aggressive behavior on the part of both partners. Borderline and dependent personality features tend to exhibit higher levels of verbal aggression and low relationship satisfaction. Higher narcissistic personality features in one partner correlate with lower partner marital satisfaction. In contrast, higher dependent personality features correlate with higher marital satisfaction. In

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short, personality-disordered individuals have a greater likelihood of being generally unhappy in their relationship, but more important, they may fail to recognize that the source of their unhappiness is their own way of processing and interacting with the world (South, Turkheimer, & Oltmanns, 2008). Women in relationships diagnosed with Borderline Personality Disorder demonstrated less marital satisfaction, higher attachment insecurity, and higher levels of inter-partner violence than those without the disorder. Similarly, these women evidenced more negative behavioral patterns in conflict resolution discussions. They were more likely to engage in criticism/attack/ conflict behaviors, such as blame, criticism, threats, non-verbal hostility, and escalation, than their male partners (de Montigny-Malenfant et al., 2013). While any combination of personality disorders is possible within an intimate relationship, some combinations appear more often in couple therapy. The underpinnings of certain personality disorders’ mutual attraction may reflect the complementary strengths and weaknesses rooted in early parent–child relationships. Where more psychologically healthy persons seek a partner based on shared worldview, mutual interests, and goals, individuals with Narcissistic or Borderline Personality Disorders may feel innately incomplete or defective and will unconsciously seek out a partner to correct or satisfy those deficiencies. Unfortunately, the qualities that first attract the disordered individuals to one another eventually become the basis of their conflict (Sperry, 1978). As each partner perceives the other more negatively, cooperation decreases while defensiveness and blaming increase, and neither partner takes responsibility for their relational problems. DSM-5 and Relational Distress DSM-5 does contain a V-code for relational distress. It is category called: Relationship Distress With Spouse or Intimate Partner and is coded as V61.10. Basically, this code is used when treatment focuses on the quality of the intimate partner relationship or when the quality of that relationship is negatively impacted by the course or treatment of a medical or mental disorder. Irrespective of gender of the partner, this code represents a broad range of distressing or impaired functioning conditions or circumstances. Common issues appropriate for this code include: conflict relationship difficulties, partner over-involvement or withdrawal, or chronic anger, apathy, or sadness about the other partner. It is important to note that this code is not to be used for the provision of sex counseling, mental health treatment of partner abuse, or for divorce and separation. Instead, DSM-5 provides separate codes for these (American Psychiatric Association, 2013). Standardized Diagnostic Inventories The use of standardized diagnostic inventories can be quite useful in identifying and confirming the diagnoses of symptom disorders and personality

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disorder. Many therapists that I  know routinely use the Millon Clinical Multiaxial Inventory with all their clients, including couples (Sperry, 2012; Nurse  & Sperry, 2012). The main reason is that the MCMI-IV, the most recent version, assesses symptom disorders as well as personality styles and disorders with DSM-5 diagnoses. It includes scales for all the personality disorders as well as the following symptom disorders: Generalized Anxiety Disorder, Somatic Symptom Disorders, Bipolar Spectrum Disorders, Persistent Depressive Disorder, Alcohol and Substance Use Disorders, Post-Traumatic Stress Disorder, Schizophrenic Spectrum Disorders, Major Depressive Disorders, and Delusional Disorders. Besides specifying DSM-5 diagnoses, the computer-generated report can be quite helpful in suggesting treatment strategies (Millon, Grossman, & Millon, 2015). The MCMI is also recognized state and federal courts and is routinely used by therapists who provide testimony as expert witnesses. Case Conceptualizations This section introduces case conceptualization and its clinical value and utility. Then it describes the centrality of patterns in conceptualizing cases, as an introduction to discussing individual and couple case conceptualizations. Let’s begin with a definition and description of their clinical value. Case conceptualization is a method and strategy for obtaining and organizing information about a partner or couple, understanding and explaining maladaptive patterns, focusing treatment, anticipating treatment challenges and roadblocks, and preparing for termination (Sperry, 2010b). In short, a case conceptualization reflects how a therapist thinks about, or conceptualizes, the clients’ presenting problems and concerns. It inform all aspects of treatment, including who should attend sessions, the type of therapeutic relationship, and the choice of therapeutic interventions (Gehart, 2017) Clinically useful and valuable case conceptualizations provide therapists with a coherent treatment strategy for planning and focusing treatment interventions to increase the likelihood of effecting change. They emphasize the unique context and the needs and resources that the individual or couple brings to treatment. Such case conceptualizations can be informed by a theoretical framework (e.g., CBT, narrative, solution-focused, etc.) or integrative approaches that incorporate biological, psychological, social, and cultural factors (Sperry, 2010b). At a minimum, clinically useful case conceptualization includes the client’s presentation, precipitant, predisposition, pattern, perpetuants, and personality style. The presentation is the client’s presenting problem, often a response to a precipitant that is congruent with the client’s pattern. Presentation can include specific symptoms and their severity, personal and social functioning, and medical and DSM diagnoses, as well as the history and course of symptoms. Precipitants include triggers that activate the client’s

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pattern, leading to the presenting problem. These are antecedents to symptoms, upsetting thoughts, and problematic behaviors. The key to understanding this interaction between presentation and precipitant is identifying the client’s maladaptive pattern, or consistent style of problematic thinking, feeling, and behaving. The predisposition refers to factors that foster and lead to either maladaptive or adaptive patterns. Biological, psychological, and social factors can all contribute to the predisposition. Finally, perpetuants are factors that maintain the presenting problem. Many clinicians and researchers consider case conceptualization to be one of the most challenging clinical competencies to master (Eells, 2010; Sperry & Sperry, 2012). The perceived difficulty in developing an effective case conceptualization may be one reason why many therapists neither develop nor use case conceptualizations, or they lack confidence in their ability to conceptualize cases. My experience is that both experienced therapists and trainees can easily and confidently begin to master this competency in as few as two to three hours of formal training. The training approach involves learning an integrated model of case conceptualization based on common and distinctive elements; and that emphasizes the element of pattern, i.e., maladaptive pattern. A basic premise underlies this integrative model. It is that individuals unwittingly develop a self-perpetuating, maladaptive pattern of functioning and relating to others. Inevitably, this pattern underlies the individual’s or couple’s presenting issues. Effective treatment will involve a change process in which the client and therapist collaborate to identify this pattern, break it, and replace it with a more adaptive pattern. At least two outcomes result from this change process: increased well-being and resolution of the individual’s or couple’s presenting issues. Centrality of Pattern Central to the case conceptualization, whether it is a conceptualization of one partner or of the relationship itself, pattern is the central and defining feature of the conceptualization. Pattern is defined as the predicable, consistent, and self-perpetuating style and manner in which individuals think, feel, act, cope, and defend themselves (Sperry, 2010a). Patterns can either be maladaptive or adaptive. Patterns that are maladaptive tend to be inflexible, ineffective, and inappropriate, and cause symptoms and impairment in personal and relational functioning, as well as chronic dissatisfaction. When a pattern is sufficiently distressing or impairing, it can be diagnosed as a personality disorder. In contrast, an adaptive pattern reflects a personality style that is flexible, effective, and appropriate. Effective individual therapy requires changing maladaptive patterns (Livesley, 2003). A critical part of this change is for clients to become adept at recognizing the patterns, particularly the maladaptive patterns that overwhelmingly influence their lives. Clients readily accept the idea that there

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is a ‘pattern’ underlying their behavior. The word is reassuring, for it suggests that there is order and meaning to behavior and experience. Educating clients about their patterns helps them to distance themselves from events, increases self-observation, and promotes “integration by connecting, events, behaviors, and experiences that were previously assumed to be unconnected” (Livesley, 2003, p. 274). Individual Patterns Individual partners are likely to bring long-standing problems and maladaptive patterns into their relationships. Their faulty thinking patterns and negative affective reactions can wreak havoc on partners’ efforts to enjoy intimate contact and maintain a positive attachment with the other partner. These individual patterns inevitably reflect a partner’s personality style or DSM-5 personality disorder. Relational Patterns Relational patterns, whether adaptive or maladaptive, tend to be learned by modeling well before the couple meets. Such patterns often reflect the relational patterns of the parents of both partners and appear to be part of the attraction process of the couple. Relational patterns evolve from the personality patterns of each partner. An effective case conceptualization specifies and elucidates how these factors operate and explain the couples’ relationship. These maladaptive patterns are evident in every aspect of the relationship: the amount of time spent together, the type of communication, amount, type, and timing of sexual intimacy, how problems and challenges are handled, etc. Not surprisingly, relational patterns have predictable outcomes. Unfortunately, when fully operative, as in a major disagreement, these patterns can polarize partners so that the situation seems hopeless when their differences are only a matter of degree. Or, they can protect and insulate the partners from getting too close to each other. Maladaptive relational patterns make the partners appear to be more incompatible than they might otherwise seem by polarizing the partners until they seem to represent opposite ends of the continuum of intimacy. Five different relational patterns were previously described in the Assessment section of this chapter. Individual Case Conceptualizations The author advocates for developing and writing three case conceptualizations when working with couples: individual case conceptualizations for each partner and a couple case conceptualization for the relationship. At a minimum, a clinically useful individual case conceptualization includes the personality style/disorder and maladaptive pattern of each partner. For example, a partner with an attention-getting pattern typically reflects a histrionic

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personality style or disorder. Similarly, a partner with overly conscientious and perfectionistic pattern usually reflects an obsessive–compulsive personality style or disorder. Couple Case Conceptualizations While every therapeutic approach has its own unique method of case conceptualization, most approaches for working with couples involve relational interaction patterns as part of the couple case conceptualization. “Specifically, therapists focus on identifying the problems interaction cycle around the presenting problem. Typically, couples and families have one or two basic patterns of interaction that characterize the presenting problem” (Gehart, 2017, p. 256). Thus, the couple case conceptualization reflects and emphasizes the couple’s relational pattern(s) and explains their presenting problem or concern with this pattern in the context of their relational history. Case Example: Jennifer and Jerrod Jennifer is a 32-year-old second-generation Hispanic female with a history of Bipolar Disorder. She has been married for six years and has no children. Jennifer sought out couple therapy because she was angry, dissatisfied, and considering divorce, yet wanted her marriage to work. Her Caucasian husband, Jerrod, is a 37-year-old successful engineer and is emotionally distant and very proper. He is also rigid and not prone to compromise. Jennifer was diagnosed with bipolar II disorder and histrionic personality traits five years ago. While she did not respond well to previous medication trials for her bipolar depression, she believes that individual therapy has been somewhat helpful in calming her moods. Jennifer believes that Jerrod’s response to her mood swings for most of their marriage is that “of course, he’s concerned but he doesn’t really show it.” Because her mental condition prevents her from working full-time, Jennifer is financially dependent on Jerrod. Jennifer complains that when Jerrod returns from work he seldom shows her attention: no greetings, no hugs or kisses, and no asking about how she is doing or how her day went. Instead, he heads off to his “man cave” to read the newspaper, play on his computer, or watch television for most of the evening. She wants more contact with him and dresses up before he gets home, expecting to be hugged and kissed, talked to during dinner and afterwards. In order to increase their contact, Jennifer follows him around when he gets home and attempts to engage him in conversation. Frequently, Jerrod responds to these overtures with anger, and then withdraws further in stony silence. Sometimes, he refuses to emerge from his man cave even for dinner. This results in Jennifer feeling angry and rejected; she perceives herself to unnoticed, unloved, and rejected. This serves to increase her loneliness.

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Diagnoses, Case Conceptualizations, and Treatment Plan 1.  DSM-5 Diagnoses Jennifer: Jerrod: Relationship:

(296.89) Bipolar Disorder II, moderate severity Histrionic Personality Traits (301.4) Obsessive–Compulsive Personality Disorder (V61.0) Relationship Distress

2.  Case Conceptualization: Partner’s Maladaptive Patterns Jennifer: Needs and demands ongoing attention and feels inadequate and unloved when none is received Jerrod: Responds to emotional demands with overwork, feeling avoidance, and emotional distancing 3.  Couple Case Conceptualization: Interaction Pattern The couple is caught in a demand/withdraw pattern that is understandable given their respective individual dynamics. This interaction pattern is triggered and reinforced by Jennifer’s characteristic need for attention and Jerrod’s predictable non-response to demands, particularly of an emotional nature. Accordingly, as Jennifer seeks intimate contact in a demanding fashion, Jerrod rejects her advances in favor of time alone. 4.  Cultural Dynamics and Formulation Jennifer identifies as a middle-class Cuban American. She is highly acculturated and believes her relational concerns are caused by “personality differences with my husband.” Accordingly, no culturally sensitive treatment appears to be indicated at this time. 5.  Treatment Plan Continue with Jennifer’s individual therapy and begin couple therapy with both. The conjoint sessions would focus on rebalancing their interactional pattern. This might necessitate individual therapy for Jerrod focused on moderating his pattern of feeling avoidance and emotional distancing. Conclusion The chapter began with the observation that working with couples has become increasingly challenging because an increasing number of couples are disordered couples. The purpose of this chapter was to provide trainees as well as experienced therapists with the necessary background material for effectively working with couples in therapy. Accordingly, necessary information on the assessment process was described. Because the matter of

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diagnosis remains a sensitive issue for those trained in systems perspective, this section was extensive. Specifics were provided on how DSM-5 diagnostic criteria can be invaluable in effectively working with the disordered couple, whether one or both present with a symptom disorder or a personality disorder, or the couple presents with a relationship disorder. The case conceptualization was the final topic. Based on an integrated assessment and diagnosis, developing an individual and a couple case conceptualization was detailed, including the centrality of pattern and both individual maladaptive patterns and relational patterns. Finally, a case example nicely illustrated all of these considerations. References American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Alexandria, VA: Author. Bhugra, D., & De Silva, P. (2000). Couple therapy across cultures. Sexual and Relationship Therapy, 15(2), 183–192. Christensen, A., & Shenk, J. (1991). Communication, conflict, and psychological distance in nondistressed, clinic, and divorcing couples. Journal of Consulting and Clinical Psychology, 59(3), 458–463. de Montigny-Malenfant, B., Santerre, M. È., Bouchard, S., Sabourin, S., Lazaridès, A., & Bélanger, C. (2013). Couples’ negative interaction behaviors and borderline personality disorder. The American Journal of Family Therapy, 41(3), 259–271. Eells, T. D. (2010). The unfolding case formulation: The interplay of description and inference. Pragmatic Case Studies in Psychotherapy, 6(4), 225–254. Froude, C., & Tambling, R. (2014). Couples’ conceptualizations of problems in couple therapy. The Qualitative Report, 19(13), 1–19. Fruzzetti, A. (2006). The high-conflict couple: A dialectical behavior therapy guide to finding peace, intimacy, and validation. Oakland, CA: New Harbinger Publications. Fruzzetti, A., & Payne, L. (2015). Couple therapy and borderline personality disorder. In A. Gurman, J. Lebow, & D. Snyder (Eds.), Clinical handbook of couple therapy (5th ed., pp. 606–434). New York, NY: Guilford Press. Gehart, D. (2010). Mastering competencies in family therapy. Belmont, CA: Brooks/ Cole. Gehart, D. (2017). Clinical case conceptualization with couples and families. In J. Carlson & S. Dermer (Eds.), The SAGE encyclopedia of marriage, family, and couples counseling. (pp. 56–260). Thousand Oaks, CA: Sage. Gottman, J. (2014). Principia amoris: The new science of love. New York, NY: Routledge. Johnson, S. (2008). Hold me tight: Seven conversations for a lifetime of love. New York, NY: Little, Brown. Kasting, A. (2015). Withdraw-withdraw pattern. University of Tennessee. Retrieved from https://relationshiprx.utk.edu/2015/05/19/withdraw-withdraw-pattern/ Knobloch-Fedders, L. M., Critchfield, K. L., Boisson, T., Woods, N., Bitman, R., & Durbin, C. E. (2014). Depression, relationship quality, and couples’ demand/withdraw and demand/submit sequential interactions. Journal of Counseling Psychology, 61(2), 264–279.

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Holley, S. R., Haase, C. M., Chui, I., & Bloch, L. (2018). Depression, emotion regulation, and the demand/withdraw pattern during intimate relationship conflict. Journal of Social and Personal Relationships, 35(1), 1–23. Landucci, J.,  & Foley, G. (2014). Couples therapy: Treating selected personalitydisordered couples within a dynamic therapy framework. Innovations in Clinical Neuroscience, 11(3–4), 29–36. Livesley, W. (2003). Practical management of personality disorder. New York, NY: Guilford Press. Millon, T., Grossman, S., & Millon, C. (2015). MCMI-IV manual. Upper Saddle River, NJ: Pearson. Nurse, R., & Sperry, L. (2012). Standardized assessment. In L. Sperry (Ed.), Family assessment: Contemporary and cutting-edge strategies (2nd ed., pp. 53–82). New York, NY: Routledge. McGoldrick, M., Gerson, R., & Petry, S. (2008). Genograms: Assessment and intervention. New York, NY: W. W. Norton & Company. Nordsletten, A., Larsson, H., Crowley, J., Almqvist, C., Lichtenstein, P., & Mataix-Cols, D. (2016). Patterns of nonrandom mating within and across 11 major psychiatric disorders. JAMA Psychiatry, 73(4), 354–361. Papp, L. M., Kouros, C. D., & Cummings, E. (2009). Demand-withdraw patterns in marital conflict in the home. Personal Relationships, 16(2), 285–300. Reiss, D. (1996). Foreword. In F. Kaslow (Ed.), Handbook of relational diagnosis and dysfunctional family patterns (pp. ix–xv). New York, NY: John Wiley & Sons. South, S. C., Turkheimer, E., & Oltmanns, T. F. (2008). Personality disorder symptoms and marital functioning. Journal of Consulting and Clinical Psychology, 76(5), 769–780. Sperry, L. (1978). The together experience: Getting, growing, and staying together in marriage. San Diego, CA: Beta Books. Sperry, L. (2010a). Core competencies in counseling and psychotherapy: Becoming a highly competent and effective therapist. New York, NY: Routledge. Sperry, L. (2010b). Highly effective therapy: Developing essential clinical competencies in counseling and psychotherapy. New York, NY: Routledge. Sperry, L. (Ed.). (2012). Family assessment: Contemporary and cutting-edge strategies (2nd ed.). New York, NY: Routledge. Sperry, L., & Sperry, J. (2012). Case conceptualization: Mastering this competency with ease and confidence. New York, NY: Routledge. Tambling, R. B., & Johnson, L. N. (2010). Client expectations about couple therapy. The American Journal of Family Therapy, 38, 322–333.

PART II

Disordered Couples Today

4 THE DEPRESSED AND BIPOLAR COUPLE Chante’ D. DeLoach

D

emographic trends suggest that most adults will marry or engage in long-term partnerships during their lifetime. Relational problems are commonplace, yet can be significantly stressful given that these are often the most significant relationships people form. Modern relationships are complex and face a number of internal and external stressors that may make these unions vulnerable. Significant and protracted issues can negatively affect the relationship and each partner’s mental health (Whisman & Baucom, 2012). Research suggests that there is a mutually influencing relationship between relational discord and psychological distress. This intertwined relationship becomes even more complex in couples in which one partner has been diagnosed with Major Depressive Disorder or Bipolar Disorder. Both clinical depression and Bipolar Disorder have significant short and long-term consequences on physical and psychological health (Peterson-Post, Rhoades, Stanley,  & Markman, 2014). Romantic partnerships are potentially an important source of social support that may foster resilience and sustained health for individuals with Major Depression and Bipolar Disorder. However, these same relationships have the potential to also be the greatest stressor posing a threat to mental health. Given the large number of individuals and families affected by these disorders and the substantial impairment that may follow, identifying and understanding risk and protective factors and healthy methods of coping is critical. Thus, the purpose of this chapter is to identify and discuss the distinct ways in which couple counseling can foster individual psychological well-being, strengthen couple and familial bonds, enhance social support, and decrease recurrence of mood episodes.

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Background and DSM 5 Major Depressive Disorder (MDD) is a mood disorder that affects 16.1 million or 6.7% of all U.S. adults (National Institute of Mental Health, n.d.b). Individuals experiencing a depressive episode may experience a depressed mood the majority of the time, decreased interest in previously enjoyable activities, and social withdrawal or isolation, and may express feelings of worthlessness, hopelessness, and suicidal ideation (American Psychiatric Association, 2013). It is common to experience physiological changes such as changes in appetite, weight, and sleep patterns. Perinatal onset of depression, commonly referred to as postpartum depression, has received increased attention in light of its impact on mothers and families. Women who experience this may describe feelings of sadness, or emotional numbing, and disengagement from the new baby. Bipolar Disorder (BD) is related to unipolar depression in that individuals will experience at least one episode of depression in addition to one manic (Bipolar I) or hypomanic (Bipolar II) episode (American Psychiatric Association, 2013). BD is less prevalent than MDD, affecting 2.6% of adults in the U.S., although the majority of these cases are considered severe (NIMH, 2015). Indeed, Bipolar Disorder is a persistent condition characterized by recurrent episodes across an affected individual’s lifespan that often results in significant psychosocial impairment or debilitation (Miklowitz  & Johnson, 2006). Both types of BD are characterized by mood polarity. With Bipolar I, the person experiences a full-blown manic episode and may have exuberance and high amounts of energy and irritability accompanied by decreased need for sleep. They may engage in risky behaviors and may have racing thoughts and speech that are difficult for others to follow (American Psychiatric Association, 2013). With the hypomanic episodes experienced with Bipolar II, the person experiences many of the same symptoms, but for shorter duration or less severity. Notably, depressive symptoms are often more common and more severe than the manic or hypomanic episodes (Vieta, 2013). It is important to note that across these disorders, a person may experience numerous episodes, often leading to significant impairment. Psychosocial and Interpersonal Stressors and Functioning MDD and BD may negatively impact interpersonal relationships and can affect relational decision-making, including mate selection and decisions to maintain or dissolve a relationship. While persons with BD are less likely to establish long-term romantic partnerships, they are also more likely to experience relational distress and divorce should they marry (Rowe & Morris, 2012). Yet, partners may not have conscious awareness of how these symptoms impact their judgment and therefore are disempowered to change maladaptive patterns (Hewison, Clulow, & Drake, 2014).

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Research on intimate partnerships in which one partner has been diagnosed with MDD or BD suggests that there is a bidirectional relationship between relationship discord and the onset and maintenance of depressive symptoms (Whisman & Baucom, 2012). People who report greater degrees of relational distress are more likely to experience mental health issues. In addition, depressive symptom severity is greater when partners report lower relationship adjustment. Yet, chronology and causality are less clear. Much of the research on distinct psychosocial and relational stressors has focused primarily on unipolar depression although the neurobiological correlates and symptomatology appear to be similar (Miklowitz  & Johnson, 2006). Thus, depressive episodes will be discussed broadly to include both unipolar and bipolar depressive episodes, differentiating only when there has been a difference identified in the research. The specific aspects of MDD or BD and the distinct ways in which relationships are affected are complex and will be discussed below. Depressed partners often demonstrate a range of depressive behaviors that complicate romantic partnerships, such as criticism of self and overall negative evaluation of life and the future, social withdrawal, and other forms of social impairment. This overall negativity may be directed toward one’s partner directly as well as indirectly through devaluation of the relationship and negative verbal and non-verbal communication (Whisman & Beach, 2015). Other depressive behaviors, such as heightened reassurance seeking—which often elicits negative feedback from others, including one’s partner—and social alienation, have also been identified. Over time, this can diminish trust, reduce emotional and physical intimacy in the relationship, and result in the loss of social support of one’s partner. Specific life events predict both unipolar and bipolar depressive episodes, worsen symptom severity, or lengthen time to recovery, including: low social support, neuroticism (being more prone to negative mood, worry, anxiety), and negative cognitive styles (Miklowitz & Johnson, 2006). Less is known about the specific predictors of manic episodes yet point to the intersection of heritability, excess dopaminergic pathway sensitivity, and sleep/wake dysregulation (Miklowitz & Johnson, 2006). Yet, more research is warranted. Being in a relationship with someone experiencing BD has unique challenges given its severity and potentially chronic debilitation. Partnerships are often plagued with instability. Partners of someone with BD report high levels of caregiver burden and relational distress, as well as higher risk for being diagnosed with a psychological disorder themselves (Granek, Danan, Bersudsky,  & Osher, 2016). In addition, these partners report bearing a disproportionate responsibility of household and child-related duties and significant emotional impacts such as helplessness, loneliness, embarrassment, anxiety, and fear related to relapse and feelings of being unappreciated by and resentful of their partners. Understandably, one study found that a

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diagnosed partner’s manic symptoms were associated with lower reports of couple functioning (Miklowitz & Johnson, 2006). While clearly spouses with partners diagnosed with BD report a range of difficult emotional experiences, some also report positive ways in which they are impacted. Some partners note that they have personally evolved and become more empathic, resilient, and have greater perspective on what their partner manages (Granek et al., 2016). This research substantiates the extent to which MDD and BD affect not only the individual but also the entire family unit. Emotional expression refers to the extent to which loved ones express criticism, hostility, and emotional over-involvement (Peterson-Post et  al., 2014). Family members and partners may become frustrated, critical, and blaming when their efforts at social support and fostering change in the diagnosed partner do not result in their preferred outcome. Yet, this actual and perceived criticism appears to play an essential role in depression. Increased perceived criticism predicts depression recurrence, worsening depressive symptoms, or negative affect (Whisman & Beach, 2015). Specific relational stressors have been identified as potential precipitants of depressive episodes such as infidelity, verbal and physical aggression, and threats of relationship dissolution (Whisman  & Beach, 2015). Partner mental health appears to be important as well. One study indicated that partners’ potential personality pathology was also positively correlated with greater amounts of relational distress (Sheets & Miller, 2010). Thus, these are important variables for individual and couple therapists to identify. For example, for a depressed couple, one partner’s threats of divorce may trigger a depressive episode. Intervening with these specific relational stressors is critical to increase support for the diagnosed partner and to enhance relational satisfaction. While this research is compelling and provides guidance to therapists working with individuals and families affected by MDD and BD, much of the research has been conducted primarily with white heterosexual married couples relatively early in their marriages. There has been some limited research with established couples. In longitudinal research with couples married on average 13 years with two children, researchers have found that the cyclical relationship between depressive symptoms and marital discord remains present even over time in established partnerships (Kouros, Papp, & Cummings, 2008). Partners may experience empathy reduction and may become frustrated and even resentful the longer they are in a relationship, which increases relational distress. How marital distress manifests is also important. Specifically, hostile marital conflict is positively associated with increased depressive symptoms. This finding is even more pronounced with couples in long-term partnerships. Some argue that the absence of marital conflict may reflect emotional disengagement, which may be more damaging to the relationship, yet many depressed individuals are at high risk for emotional withdrawal (Kouros et al., 2008).

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Lastly, because MDD and BD affect the entire family unit, it is important to consider how children are affected. A  depressive or manic episode can negatively affect one’s ability to fully participate in parenting. Research has indicated that depressed parents may have difficulty meeting infant needs, which can result in emotional instability, disrupt maternal attachment, and increase risk of depression later in life for the child (Hewison et al., 2014). Marital conflict has been demonstrated to negatively affect children, particularly overtly hostile or violent conflict. Thus, clinicians must be keenly attuned to the myriad ways in which other members of the family may be affected. Moreover, couple therapy may serve as a preventive effort or early intervention for children within depressed families and thus have intergenerational effects (Hewison et al., 2014). Assessment and Treatment Using an integrative case conceptualization that is grounded in systems theories (Stanton & Welsh, 2012) and also integrates clients’ understanding of issues and client-derived treatment goals, Sperry (2005) fosters a holistic understanding of clients and their presenting concerns. It is important to assess each partner’s view of the relationship and the onset and course of the primary issues. From a strengths-based perspective, it is also important to assess individual and relational strengths. Unique considerations in working with couples in which mental health issues are present include an assessment of the presence and severity of symptoms for the diagnosed partner. It is noteworthy that the diagnosed partner and their illness is often viewed as the problem within their familial context. However, from a systems perspective, this partner’s symptoms may be indicative of larger problematic relational and familial dynamics (Kelly & Boyd-Franklin, 2009). Despite conceptualizing the diagnosed partner’s concerns within the larger systemic context, it is important to understand the very real ways in which this person’s well-being may be impaired and the multiple types of support needed. If the diagnosed partner is under the care of an individual therapist, the couple therapist should coordinate care. Individuals diagnosed with BD likely require pharmacological treatment to regulate mood in order to effectively participate in and benefit from couple therapy. Because depression and BD are comorbid with suicidality, it is important that even if a partner is seeing an individual therapist that the couple therapist be attuned to any signs of suicidality. Importantly, if a partner is actively suicidal, couple therapy may not be a suitable therapeutic modality until suicidal ideation is resolved. Assessing whether couple therapy can be a stand-alone treatment is important at the outset of therapy. One recommended metric in this decision is assessing the chronology of depressive symptoms and the salience of relationship difficulties for the diagnosed partner (Whisman & Beach, 2015).

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When an individual with depression or BD views their relationship struggles as being central to either contributing to or maintaining their psychological state, couple therapy is likely to be beneficial (Whisman  & Beach, 2015). Partners in discordant relationships may be less responsive to individualbased treatments alone. including pharmacotherapy and empirically supported therapies. Further, individual treatment of a mental health condition is often not associated with improvements in relational functioning. Thus, assessment of relational satisfaction and communication styles (including expressed emotion), as well as the presence of psychological symptoms (for all partners), is important to identify specific risk factors as targets for couple therapy. Couple therapy, like any clinical work, is by its very nature a social and cultural encounter. It necessarily requires cultural consideration and distinct modifications based upon individual and couple cultural and spiritual backgrounds and social factors such as same-sex couples, or families from low-income or low-resource backgrounds (Kelly  & Boyd-Franklin, 2009; Whisman & Beach, 2015). Therapists are challenged to make services accessible and effective across areas of human difference. Ongoing assessment of relationship satisfaction, psychological well-being, and the effectiveness of treatment is critical to the course of treatment. Treatment Considerations An exhaustive review of individual treatment for MDD and BP is outside of the scope of the present discussion. As previously stated, MDD and BD are chronic health conditions that can result in severe impairment and can negatively affect quality of life for those affected. Therefore, couple therapy as a solitary treatment may not be assessed as appropriate. In addition, some partners’ individual functioning may render them unable to participate in or benefit from couple therapy until their symptoms are stabilized. Thus, individual treatment as well as pharmacotherapy may be a necessary initial step for some clients. Moreover, pharmacotherapy is considered standard treatment for the management of BD (Vieta, 2013). Yet, it is noteworthy that up to 60% of diagnosed individuals are non-adherent, which can increase risk of relapse and suicidality (Vieta, 2013). Thus, other psychosocial treatments are an important component of overall treatment. Most treatments for BD include psychoeducation about the illness, methods of identifying symptoms and implementing relapse prevention procedures, and the promotion of treatment adherence and ways to minimize risk factors such as stressful life events and increase protective factors such as social support and schedule regularity. As previously stated, the role of intimate relationships and family is an essential resource and potential stressor for individuals diagnosed with MDD or BP. Thus, family and couple therapy are important treatment modalities.

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Couple Therapy and Depression and BD Couple therapy has long been identified as a valuable adjunctive treatment for depression (Whisman & Beach, 2015). Early advocacy for couple therapy for depression underscored its utility as a social support mechanism. Clinical research suggests that couple therapy is comparable in effec­tiveness to that of individual treatment in reducing depressive symptoms and is more effec­­ tive than individual therapy in the improvement of relationship satisfaction and in achieving specific couple goals such as reduced criticism (­ Whisman & Beach, 2015). Similarly, some limited research suggests that marital psychoe­ ducation sessions provided to partners of BP patients demonstrated better functioning overall and drug adherence (Vieta, 2013), lower rates of relapse, and less severe symptoms (Miklowitz, George, Richards, Simoneau, & Suddath, 2003). Couple therapy may be beneficial when relational stress has played a role in the onset or maintenance of depressive symptoms or as an adjunctive therapy to each partner’s individual therapy to provide psychoeducation and as a space to specifically focus on relational dynamics, improvements to communication, and problem-solving skills. Taken together, this research demonstrates that a multipronged clinical focus may be necessary and that working to improve the relationship can help the couple as well as the mental health of both individual partners (Epstein  & Baucom, 2002). For purposes of the present discussion, a brief outline of the stages of couple therapy for depression will be presented given its empirical support. These stages of couple therapy for depression are also aligned with other couple models; it can thereby be easily integrated with other couples theoretical approaches. Initial Stage Following assessment, the initial stage of therapy focuses on the strengths of the relationship and establishing realistic goals and expectations of couple therapy and individual change (Whisman & Beach, 2015). This may include information about expected timeline (couple therapy for depression is typically around 20 sessions or fewer for non-complicated cases) as well as the importance of work outside of sessions. Early interventions include homework outside of sessions to increase positive interactions and activities that foster feelings of support in the relationship. This is important in the beginning of work with couples with histories of depression, as they may be especially sensitive to what they experience as a ‘lack of progress’ due to negative evaluations (Whisman & Beach, 2015). During this phase, each individual partner is tasked with performing caring gestures, whether they experience their partner as successively engaging in this behavior or not. Other interventions used in this phase include partners verbally expressing appreciation (also referred to as self-esteem support) and engaging in pleasurable activities such as date nights. Through this stage, couple therapy seeks to interrupt

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the pattern of low cohesion and decreased intimacy by facilitating increased positive interactions, healthier reality-based communication, and enhancing intimacy (Whisman & Beach, 2015). Second Stage During the second phase of therapy, partners work to increase communication and foster problem-solving skills. The therapist provides psychoeducation around positive communication skills, such as using “I” statements, active listening, and non-verbal communication skills. They begin practicing this in session and at home on neutral topics, and then move forward working on smaller problems, building toward problem-solving the larger issues within the relationship. Through enhancing problem-solving skills, partners are directed to decrease negative communication behaviors while increasing positive communication. The role of the therapist is key in facilitating these dialogues, intervening, and providing tools for prosocial communication. For example, partners work to reduce criticism through psychoeducation about depression and meaning ascribed to the depressed partner’s behavior (Whisman & Beach, 2015). There may be a resurgence of negative affect as couples begin to more actively work through relational issues. Therapists are encouraged to remind couples to use the social support skills and positive communication practiced during the initial phase during this time. Final Stage The final stage is focused on the maintenance of change and applying what has been learned to future challenges (Whisman & Beach, 2015). For example, couples might discuss an upcoming job change and how they might cope with a life transition. Clients are encouraged to discuss what they have learned in session as well as outside of session. Some couple therapists recommend having couples put this in writing to reference and reflect on later (Whisman & Beach, 2015). Ultimately, clients are empowered to trust and apply what they have learned and decrease dependency on therapy and the therapist. Yet, it is noteworthy that couple therapy should be promoted as a future resource and that check-ins are encouraged at high-risk times. The treatment of couples facing depression or BD can be complex and requires attention to multiple factors in addition to the presenting psychopathology. Cultural factors and issues of individual difference as well as relational satisfaction, couple dynamics, and other systemic issues must be considered. Below, many of these issues will be explored in a case example. Case Example: Michelle and Brian Michelle (age 28) and Brian (age 32) are an African American couple who have been together for three years and cohabitating for the past two years.

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They presented for counseling due to reports of conflict, difficulty communicating, and decreased sexual intimacy in their relationship. Michelle was diagnosed with Bipolar Disorder II a few years prior to their relationship. The present therapist worked with Michelle individually for five sessions related to her diagnosis, volatile relationship and work history, and familyof-origin issues. She prematurely dropped out of counseling and returned for couple therapy a few years later with Brian. Michelle and Brian met through a popular dating app and both reported that they instantly connected. They described the beginning of their relationship as being full of excitement, fun, and passion. They both identified their friendship and shared values as strengths of their relationship. Michelle stated that she disclosed her BD diagnosis with Brian “later than [she] should have.” She admitted that was still in denial and reportedly struggled with whether the diagnosis was accurate or the extent to which she needed to take such “heavy medicine” that made her feel like someone else. Michelle stated that just before meeting Brian, she attempted to manage her BP using natural methods that was more aligned with her philosophy on life and her desire to remain unmedicated, but it did not result in stabilizing her mood. Approximately four months into the relationship, Michelle experienced a depressive episode and emotionally withdrew from Brian and others around her. She reportedly did not want to talk to Brian about what she was experiencing, but it began to affect their relationship the more Michelle pulled away from him. Brian reported that initially he took what was happening with Michelle personally as he thought she was losing interest in him. Brian grew up witnessing his mother deal with what he now believes was depression. Michelle stated that he responded with compassion and took care of her during this time, which allowed her to feel safe opening up about her mental health history. He encouraged her to see her previous psychiatrist and resume medications. Both Michelle and Brian stated that the experience drew them closer together. Michelle noted that things improved and they moved in together a few months later. The next couple of years reportedly were plagued by a lot of “ups and downs.” Michelle stated that during this time, she was “mostly” on her medications, but Brian questioned whether she was being honest. Brian noted that there were times when they were connected and Michelle was passionate and engaged, and other times when Michelle was disconnected and disinterested in sex. They also had dramatic arguments, one of which resulted in a neighbor calling the police reporting that Michelle was crying so loudly and uncontrollably that he assumed she was hurt or being abused. During arguments, Brian often threatened to leave her and the “crazy relationship.” Brian admitted to having called her a “drama queen” out of anger on one occasion, which he regretted. Ultimately, Michelle did not feel like Brian trusted her own assessment of how she was doing and treated her like a child and was no longer as sensitive to her needs. She reported feeling

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like every problem in the relationship was blamed on her and her mental health struggles. Both reported having grown to resent the other for different reasons. Initial Stage of Therapy This therapist began by acknowledging the brief history with Michelle and assessing Brian’s comfort in working together. Brian stated that he felt better working with someone Michelle trusted and who knew Michelle’s complex history. Both stated that it was important for them to work with an African American therapist who specialized in couple issues. At the beginning of therapy, it is important to begin with the joining process. This is even more important for African American clients, who may lack experience with counseling or may mistrust health care providers (Kelly & Boyd-Franklin, 2009). In my work with couples, I intentionally employ a systemically oriented and culture-centered model of treatment that is supported by empirical and practice-based evidence (DeLoach, 2013; Kelly & Boyd-Franklin, 2009). This approach works well with the process outlined in couple therapy for depression. Thus, in my work with Michelle and Brian, I began the joining process by using professional self-disclosure and humor to make both partners feel at ease. I also invited the couple to ask me any questions that might be important for them in working with me. Assessment was a critical initial component of my work with this couple. In the initial joint session, I gathered background information about their relationship, its strengths, and its challenges. Brian clearly viewed their issues as being about Michelle’s “unmanaged Bipolar Disorder.” Michelle viewed their issues as being about their difficulty communicating, trust, and questions about Brian’s commitment. Following the joint session, I scheduled two individual sessions to gather additional individual relationship and family history. In addition to joint and individual clinical interviews, I ­administered objective measures of relational satisfaction and a brief psychological symptom instrument. Results indicated that both partners reported moderately low levels of satisfaction with the relationship. Brian reported sub-threshold but notable levels of anxiety, while Michelle endorsed clinical levels of depression and moderately high levels of anxiety. These results were further explored in their individual interviews. Based on Michelle’s background and questions about treatment consistency, it was important to assess her present symptoms, current methods of treating symptoms, and coping strategies. In the individual session, Michelle revealed that she had not been in therapy for years and had experienced a number of side effects from her medications, which resulted in her only taking the antidepressant and discontinuing the mood stabilizer. Michelle reported not being close with her family due a family history of mental

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illness and addiction. Her parents had been married for over 30  years yet had a tumultuous marriage when she was young. Her father was a pastor in a conservative Christian denomination and struggled with undiagnosed alcoholism. She stated that when he was intoxicated, he was verbally abusive to her and her mother. She questioned whether he was also violent with her mother at times. Her mother was morbidly obese, struggled with a host of medical problems, and took pride in being a “submissive Christian wife.” She stated that she also believed that her mother had an anxiety disorder, but that this was undiagnosed as her family believed in prayer (but not therapy) as this was an indication of lack of faith. Michelle disclosed that the relationship with Brian was the longest relationship she had been able to maintain and feared losing him. Since being in the relationship, she felt more stable and had only changed jobs one time, which was an accomplishment for her. Her primary concern was their communication and that he trusted her to take care of herself. In the individual session with Brian, I learned that he was raised primarily by his mother and maternal grandmother. His mother had intermittent bouts of what he believed to be depression where she would stay in bed for long periods and lock herself in a room. She experienced periods of unemployment, which resulted in financial instability for them throughout his childhood. Brian reported that his grandmother was the person who kept him out of trouble, ensured he had everything he needed, and would attempt to nurse his mother back to health. Brian has one older brother who has been incarcerated off and on for their adult lives due to petty crime. His brother’s experience with the criminal justice system led to his work advocating for justice reform. Thus, his professional work is personally meaningful yet difficult. Regarding romantic relationships, Brian noted that while he had relationships prior to Michelle, they were shorter and often with women who were more “traditional” than Michelle. He stated that he loved Michelle but could not “work harder for her mental health than she does.” Brian reportedly had the most difficulty with the “dramatic and angry outbursts” and agreed to come to counseling to see if they could learn to better communicate. He admitted to having “one foot out the door” if she did not stay on her medications. He noted that he had dealt with his “mother’s problems for [his] entire life and would not deal with it as an adult.” As a systems therapist, I was particularly concerned about and sensitive to Michelle being labeled as the identified patient in the relationship and her sense that all of their problems were being blamed on her. Based on my initial assessment, I did not believe that couple therapy as a stand-alone treatment was sufficient for this couple. Michelle’s symptoms were not well managed and Brian could also benefit from individual space to explore his relationship with his mother and her struggles with mental health. I recommended that in addition to couple counseling, that they each see an individual therapist. Specifically for Michelle, I referred her to a psychiatrist who also provided

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individual counseling services. They both signed releases to allow the coordination of treatment across therapists. During this initial phase of therapy, I built upon this couple’s strengths (their friendship and ability to have fun together) to enhance positive emotions and interactions. Between sessions, they were instructed to increase the number of positive affirmations, non-sexual touch, and at least one date. Notably, they were both excited about engaging in this as they continued to enjoy time together. They did, however, express hesitance that their communication problems would “ruin” a potentially positive outing. In the following sessions, the couple reported some modest improvements in cohesion and reportedly had sex on a few occasions. They stated that while they did argue during this time, the arguments were not quite as bad. In the next sessions, I worked to provide psychoeducation about Bipolar Disorder as a chronic condition and the importance of social support. I utilized enactment within the sessions to: (1) assess the couples’ structure and communication pattern; and (2) better understand their communication patterns and any influencing factors such as familial and relational history or mental health symptoms. The couple initially engaged in discussion about relatively minor household and personal decisions that had been a point of minor tension. Through these enactments, I  was able to identify a number of additional strengths. First, they were mutually respectful in the conversation and both gave one another time and space to voice their concerns and feelings. They were at once vulnerable and open in the discussions, which demonstrated that they felt emotionally safe with one another as well as with the therapist. Despite the conversation being about household responsibilities, they were able to connect time and emotional labor as a valuable resource. For example, Brian expressed support for Michelle’s desire to have more time to work on her writing, which she often does not have time to pursue. Michelle was also able to acknowledge and affirm the often invisible contributions Brian made, such as putting gas in the car they shared. Through these initial conversations, I assessed that their communication skills were better than they initially assessed, but some topics and emotions were more difficult. I observed that in the face of Michelle’s expressions of anger or disappointment with him, Brian responded with defensiveness and emotional withdrawal. Brian’s response appeared to be a trigger for Michelle, and this resulted in an escalatory spiral with her becoming increasingly angry and more emotionally reactive. At one point, this triggered comments from both partners about unresolved issues. For example, when Michelle stated that she sometimes felt that he treated her like a child and that it bothered her when he shut down emotionally, Brian retorted: “That’s not how it is. And if it was, it’s only because you don’t act like a grown woman!” At this point, I intervened and deconstructed both the process and content of communication. This work took time, yet the couple was encouraged to continue to

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strengthen positive contact outside of therapy and engage in assigned homework. This resulted in the couple having multiple discussions about power dynamics in their relationship. Second Stage of Therapy The second stage of my work with this couple involved building upon their existing communication strengths. It is noteworthy that as we entered this phase of therapy, Michelle also reported improvements in mood as a result of new medication. Both partners noted that she seemed to feel more balanced and reported more energy and motivation. As observed early in our work, Brian and Michelle already had positive expressive and receptive communication in their lexicon. The challenge for this couple was to identify triggers and to slow down the interactional dance (as described in emotionfocused couple therapy). In addition, it was important to reduce the criticism that emerged in times of conflict. Soon, they began to apply information and strategies learned in the initial phase of therapy to engage in difficult discussions around the implications of Bipolar Disorder for them in the long-term. They reflected on difficult considerations such as trust and Michelle’s ability to adhere to treatment. Brian was able to hear Michelle’s sense of loss and pain around accepting that she had been diagnosed with a chronic condition that could not effectively manage using natural approaches. She was also able to own that her reasoning for not being open with Brian had more to do with previous experiences than who he is as a person. Brian was able to provide empathy and own that his experience with his mother had left him sensitive to these issues. He concluded that he wanted to support her but he needed to understand what is helpful from him as a partner. This series of conversations both within and outside of session was powerful in how it allowed them to reflect on their relationship structure, power dynamics, and intergenerational issues. Both partners were able to acknowledge influencing family-of-origin issues and ways that trust became issues for them. Final Stage of Therapy In the final phase of therapy, the couple had begun demonstrating more consistent positive communication patterns even through challenges with medication side effects for Michelle as well as stressful work-related issues. The last set of difficult dialogues focused on future questions around pregnancy and the fears around medication, genetic risks, and the potential impact of stress and hormones of pregnancy and postpartum for Michelle. In these discussions I was able to observe Brian soften and turn toward Michelle when she expressed vulnerability, especially shame. He offered emotional support in a way that appeared to be helpful for Michelle. They were also both able to use appropriate humor during conflict.

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Overall, my work with this couple was heartening in that they were more committed to one another and the therapeutic process than they initially expressed. They built upon existing strengths and were successful in large part due to their openness and commitment to the therapy process. It is noteworthy that both partners were also in individual counseling and Michelle was also benefiting from pharmacotherapy, all of which helped achieve treatment outcomes. Follow-up and relapse prevention sessions are pending for these clients to assess long-term effectiveness of this work. Conclusion Overall, research on relational functioning and psychological distress indicates the presence of a bidirectional, intractable relationship. Yet, there appear to be distinct intrapsychic and relational variables that are important to clinically evaluate within the context of therapy. Specifically, the presence of criticism, acts of humiliation, threats of leaving the relationship, and caregiving burden are important areas of prevention and clinical intervention. Less is known about cultural differences and distinct challenges and methods of coping for couples across cultural backgrounds and SES, as well as same sex and non-monogamous relationships. Despite these limitations in the research, there is much for couple therapists to glean for its clinical utility. Importantly, it is clear that stress within romantic partnerships can be a trigger for depressive symptoms. These same relationships can also serve as potential sources of support and can prevent depressive episodes. Thus, couple counseling can serve as a potentially powerful source of prevention and early intervention for couples managing depression and BD. In light of the research identifying that both partners’ mental health is important to foster relational stability and prevent depression relapse, the role of psychoeducation, positive communication, and constructive conflict strategies likely serve key roles to couple success as well. Couple therapy may serve a role in improving bilateral empathy (Granek et al., 2016), which is critical in light of limitations in partners’ perspectives of one another’s struggles. Taken together, couple-based intervention has the potential (when appropriate) to reduce individual symptomatology and to improve relational functioning. References American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing. DeLoach, C. (2013). Couples therapy with Black couples: Specific treatment strategies and techniques. In K. Helm & J. Carlson (Eds.), Love, intimacy, sex, and the Black couple. London: Routledge. Epstein, N. B., & Baucom, D. H. (2002). Enhanced cognitive–behavioral therapy for couples: A contextual approach. New York, NY: American Psychiatric Association.

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Granek, L., Danan, D., Bersudsky, Y., & Osher, Y. (2016). Living with bipolar disorder: The impact on patients, spouses, and their marital relationship. Bipolar Disorders, 18(2), 192–199. Hewison, D., Clulow, C., & Drake, H. (2014). Couple therapy for depression: A clinician’s guide to integrative practice. New York, NY: Oxford University Press. Kelly, S., & Boyd-Franklin, N. (2009). Joining, understanding, and supporting Black couples in treatment. In M. Rastogi & V. Thomas (Eds.), Multicultural couple therapy (pp. 235–254). Thousand Oaks, CA: Sage. Kouros, C. D., Papp, L. M., & Cummings, E. M. (2008). Interrelations and moderators of longitudinal links between marital satisfaction and depressive symptoms among couples in established relationships. Journal of Family Psychology, 22, 667–677. Miklowitz, D. J., George, E. L., Richards, J. A., Simoneau, T. L., & Suddath, R. L. (2003). A  randomized study of family-focused psychoeducation and pharmacotherapy in the outpatient management of bipolar disorder. Archives of General Psychiatry, 60, 904–912. Miklowitz, D. J., & Johnson, S. L. (2006). The psychopathology and treatment of bipolar disorder. Annual Review of Clinical Psychology, 2, 199–235. National Institute of Mental Health. (2015). Bipolar disorder. Retrieved from: https://www.nimh.nih.gov/health/statistics/bipolar-disorder.shtml National Institute of Mental Health. (n.d.b). Major depression among adults. Retrieved from www.nimh.nih.gov/health/statistics/prevalence/major-depression-amongadults.shtml Peterson-Post, K. M., Rhoades, G. K., Stanley, S. M., & Markman, H. J. (2014). Perceived criticism and marital adjustment predict depressive symptoms in a community sample. Behavior Therapy, 45(4), 564–575. Rowe, L. S., & Morris, A. M. (2012). Patient and partner correlates of couple relationship functioning in bipolar disorder. Journal of Family Psychology, 26(3), 328–337. Sheets, E. S., & Miller, I. W. (2010). Predictors of relationship functioning for patients with bipolar disorder and their partners. Journal of Family Psychology, 24(4), 371–379. Sperry, L. (2005). Case conceptualization: A strategy for incorporating individual, couple, and family dynamics in the treatment process. American Journal of Family Therapy, 33, 353–364. Stanton, M., & Welsh, R. (2012). Systemic thinking in couple and family psychology research and practice. Couple and Family Psychology: Research and Practice, 1(1), 14–30. Vieta, E. (2013). Managing bipolar disorder in clinical practice. New York, NY: Springer. Whisman, M. A., & Baucom, D. H. (2012). Intimate relationships and psychopathology. Clinical Child and Family Psychology Review, 15, 4–13. Whisman, M. A., & Beach, S. R. H. (2015). Couple therapy and depression. In A. S. Gurman, J. L. Lebow, & D. K. Snyder (Eds.), Clinical handbook of couple therapy (5th ed., pp. 585–605). New York, NY: Guilford Press.

5 THE PSYCHOTIC COUPLE Michael P. Maniacci and Len Sperry

The Experience of Psychosis in an Intimate Relationship

I

was 18 and Jon was 23 when we met at the university. He was brilliantly intelligent, sociable, and eccentric. Five years later we married. . . . Jon did behave a bit strangely sometimes, but then so did many other people I knew. His relationship with his parents struck me as rather odd, but since we came from very different backgrounds, this didn’t really worry me. Besides, Jon’s explanations were so beautifully rational and convincing. . . . If I had to give a single reason why life with Jon became unbearable, I would say it was my growing feeling of guilt. I already had a tendency to feel guilty well before meeting my husband. But after I  married, this tendency prevailed. I felt guilty because I could neither ease his suffering nor give him the confidence he lacked so dramatically. But most of all I felt guilty because I began to resent the endless struggle of dealing with Jon’s strange world and the endless daily complications it brought about. The strain of being the only link between him and the outside world, of having to translate his behavior to our daughters, of not being able to talk to them without being accused of collusion, of having to adapt to his unpredictable moods and having to live with ghosts, all those wore me down. . . . I felt like fleeing from this situation, but how could I abandon him? . . . I became increasingly snappy and irritable. And the nastier I became, the guiltier I felt. We were caught in a vicious circle. (Anonymous, 1994, pp. 227–229)

Here the wife of a psychotic husband describes how their relationship began. Her description is quite consistent of that of most psychotic couples. Then, she points out how his mental disorder caused moderate impairment

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in his overall functioning, but severe disruption in their marriage. Again, this is commonplace among such couples. She then offers insight into what it was like to be married to a man who frequently believed “they were out to get him.” Finally, she voices her self-doubt, guilt, and feelings of isolation more clearly than many clinicians are able to articulate in “clinical” terms. Psychosis is a disruptive, difficult disorder for those who experience it, yet the quite frequently overlooked partner of the psychotic individual very often experiences considerable subjective distress and pain as well. Because of the glaring dysfunction typically evident in the psychotic partner, the nonpsychotic partner’s needs and issues are very frequently “put on hold” while the more obviously impaired partner is intensively (though often insufficiently) treated. The non-psychotic partner can be especially helpful in treatment, particularly in couple therapy. Non-psychotic partners are particularly important because they usually can predict when an acute psychotic episode in their partner is about to emerge. However, they are often frustrated in their attempts to receive the kind of professional interventions they believe are needed to prevent the disorder from deteriorating into a major psychotic episode. In short, they feel left out of the loop not only when it comes to their own needs being met but also in providing input regarding their partners (Winefield & Harvey, 1994). Unfortunately, in our opinion, this situation has not appreciably changed since the Winefield and Harvey article was published. Clinicians, especially novice ones, often become anxious in dealing with the admittedly bizarre presentations that these individuals display. Over the last three decades, pharmacological interventions have taken precedence in the treatment of psychotic people. While in many (if not most) situations, this has been quite beneficial, the psychosocial interventions first outlined by early clinicians such as Alfred Adler still are very relevant and useful to those who use them wisely (Carlson & Maniacci, 2012; Maniacci & SackettManiacci, 2019). The rise of family-based interventions during roughly the same period has also been extremely helpful (Carlson, Watts, & Maniacci, 2006; Maniacci  & Carlson, 1991). This chapter will examine how an integrated, holistic approach to couples who have an individual experiencing a psychotic episode can be conducted. A situation unique to this chapter needs to be addressed first. Psychosis itself is technically not a disorder listed in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (American Psychiatric Association, 2013). The DSM-5 enumerates specific disorders that may experience psychotic reactions, but there is no specific disorder called “Psychosis.” What they are will be detailed later in this chapter, with a special emphasis upon two variations of psychosis: psychotic reactions found in disorders such as Bipolar Disorder or Major Depressive Disorder; and in Schizophrenia or Delusional Disorder. First, a brief history is needed.

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Overview: Theory and Research on the Psychotic Couple Traditionally, three categories of psychopathology have been articulated. Though the terminology has undergone numerous revisions, the concepts themselves have been maintained, even if in somewhat obscure form. The three traditional categories have been “neurosis,” “character disorders,” and “psychosis.” Neurosis was the general designation for individuals who experienced anxiety symptoms. It is now referred to by the various anxiety disorders. Character disorders is now referred to as personality disorders. “Psychosis” was the designation reserved for those who appeared to have lost touch with reality. They had sensory disturbances such as auditory or visual hallucinations; fixed, rigid ideas that were demonstrably implausible; or extreme emotional reactions out of proportion to situations. Moreover, they experienced disturbances in their senses of self, such that functions such as “ego-control” and “reality testing” were impaired. Today, the psychotic disorders encompass disorders in the categories of Schizophrenia Spectrum and Other Psychotic Disorders, Bipolar Disorders, and in the Depressive Disorders (American Psychiatric Association, 2013). Psychological Theory of Psychosis Of all the psychological theories of psychosis, the one developed by Alfred Adler (1956, 2012) is arguably the most relevant to clinical practice today as well as being compatible with a highly regarded Neuroscience Theory of Psychosis. Adler’s view of psychosis can be summarized in six key points. 1. Adler’s earliest work as a clinician focused on what he called “organ inferiority.” An organ inferiority had to be inherited, and when it was, three laws of compensations took place (Adler, 1956; Dreikurs, 1967). Somatic compensation occurred first. The body detected an abnormality in form or function and, without conscious awareness, would take steps to adjust. The classic example he cited was kidney dysfunction. When one kidney was impaired, the other automatically took over and did the work of two. No cognitive decision was required. Sympathetic compensation came next and was also without conscious awareness. Accordingly, the body would adjust its posture, or stance, to compensate or protect the affected portion. A classic example would be a defect in one eye. While somatically, the unaffected eye might carry most of the workload, sympathetically, the body or head might unconsciously turn or angle itself so to have the healthy eye lead and therefore protect the blind spot. Psychic compensation occurred last and was under cognitive control. This involved how individuals used their organ inferiority. Some individuals with congenital hearing problems overcompensated and became master musicians. Others with the same problems might become suspicious, paranoidlike, and distrustful of others, because when they missed verbal cues from

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their social world and were made aware of it, they became defensive and accused others of lying to them or deliberately misleading them. Individuals who develop psychotic reactions typically experience some organ inferiority. In contemporary language, they have a “diathesis.” As Adler (1956) noted, an organ inferiority is dependent upon the situations in which individuals find themselves. If life is kind, many individuals may never become aware of their organic inferiorities because the affected body part or function is never severely tested. Therefore, the contemporary theory refers to the “Stress-Diathesis” Model. It is the combination of what the body has and the situation in which the body finds itself. Adler hypothesized that it was a structure or function of the brain that was impaired in psychosis, though given the medical knowledge of the time, he never specified where or what. The concept of “stress” will be addressed below. 2. They set their goals exceptionally high. Of all the disorders clinicians encounter, none are more out of proportion in their goal setting than in individuals who develop psychotic disorders. The high goal setting leads to profound feelings of inferiority and inaction. Why inaction? The larger the perceived goal, the slower the reaction time. If asked to do a simple task, individuals react rapidly. If the task is perceived to be huge, or complex, individuals tend to hesitate so as to better assess the requirements. Dreikurs (1967) considered “laziness” to be one of the key signs of “over ambition.” 3. Early childhood training was required. For individuals who would develop psychotic reactions, they had to be trained and train themselves, in three key areas. Fantasy was overused as a safeguarding mechanism. Individuals who develop psychotic strategies are often quite discouraged. Accordingly, they doubted their places in the world. Often, their over ambition meant that simply being good at something was not enough; they had to be the best. This early rehearsal in over ambition led to fantasy as a too often used tool. They could fantasize about the success they wanted, and all too often, those fantasies became more satisfying than reality. Eventually, fantasy became more important than reality. They no longer hesitated or slowed reaction time; they stood still or moved backwards (Adler, 1956). Imagination was overused as well. These people were often very creative and imaginative individuals. Whereas most people saw a tree, they could see a treehouse. While others looked to the sky and saw stars, these people saw constellations. When used constructively, these people were artistic and unique. Their unusual perspectives were original, insightful, and frequently beautiful. When discouraged and used destructively, they could be bizarre, frightening, and disorienting. The tree is not a treehouse; it is a monster or harbinger of evil or doom. Escapism becomes problematic. When challenged, everyone may need time alone to regroup, recompose, and take a break. However, psychotically predisposed individuals tend to overreact and withdraw. While most

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individuals use fantasy and imagination to practice and attune their ideas for success in the social world, the psychotically predisposed tend to escape and avoid that same world. In their escapism, they find more s­ uccess and peace then in the social world, and they begin to use it too often, too intensely. 4. Linguistic encoding becomes a problem. As Adler (1956) noted, success in the social world requires common sense, the ability and willingness to use the signs, symbols, and language of the community in a consensual, understandable way. Everyone has private logic, that is, aspects of thinking that are idiosyncratic, unique, and personal. Whereas for most people, the ratio of common sense to private logic is very heavily weighted to the common-sense side, psychotically disposed individuals shift the ratio. They overemphasize private logic, partly because of brain development and partly because of early experiences. In other words, they develop private, personal meanings that they do not test out but simply assume to be true and helpful. They use non-verbal, attitudinal, visual-spatial processing too much—functions typically associated with right hemisphere processing. They over-rely upon impressions and creativity without the verbal, typically left hemisphere processing associated with language, logic, and reasoning. They can feel their way through life but not regularly talk or reason their way through challenges. This can be very helpful many times, but when used too often and too rigidly, it can lead to panic and over reaction. 5. Given all the processes noted above, they are often drawn to the unique, sensational, and different. Surrealism quite often seems natural to them. At adolescence, while many others may experiment with substance use, they are often drawn to misuse. They overindulge. Given their biological predisposition to brain impairment, the substance use that many adolescents find entertaining and common, the psychotically predisposed find addictive and problematic. Their compromised central nervous system cannot handle the added load and something is triggered, though exactly what is still unclear. Their experimentation/use often deteriorates into dysfunction and begins a neurobiological cascade that has dire consequences. 6. Typically, they experience a discouraging family and childhood situation. Many of their home, school, and neighborhood experiences are unsatisfying at best, and dysfunctional at worst. Concepts such as “negative expressed emotion” have permeated the psychiatric literature for decades, and Adlerian clinicians have referred to such dynamics as discouraging family atmospheres (Maniacci & Carlson, 1991; Mosak & Maniacci, 1989; Shulman, 1962). Life is not simply hard; it is unfair and often cruel. They cope by increasingly withdrawing into their private worlds, with their private meanings, fantasies, and ideas. Whenever stress arises, they escape into themselves. Given their biological predispositions, it becomes increasingly difficult to find their way back.

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Neuroscience Theory of Psychosis Acclaimed neuroscience researcher Michael Gazzaniga (1988, 2006) and his colleagues (Gazzaniga, Ivry, & Mangun, 2008) have developed and articulated a Cognitive Neuroscience Theory of Psychosis that nicely explains central nervous system dysfunction. It effectively integrates research findings from both the neurosciences and cognitive psychology as is most compatible with Adler’s theory of organ inferiority and psychosis (Maniacci & Sperry, 2015). Gazzaniga proposes that individuals generate a series of internally consisted schemas or beliefs about themselves and life, which allow daily living to be both predictable and meaningful. He labels these cognitive schemas the brain’s interpreter. The interpreter does not always have correct data but must interpret this information any way the brain can. Gazzaniga further postulated an urge to create order in the information being processed, which is an effort to compensate for central nervous system dysfunction, or “organ inferiority,” as it was called by Adler. Gazzaniga (1988) believes that Schizophrenia is a disease in which the brain’s interpreter, typically the verbal, left hemisphere, attempts to create order out of what is most likely endogenous, or inner-generated, brain chaos. Brain chaos is the spurious neural actions precipitated by faulty biochemical brain states, such as sharp rises or decreases in neurotransmitters, which adversely affect the typically symbolic, image-generating right hemisphere. The interpreter makes decisions about what meaning to assign to such chaotic events. The psychotic process in general, and Schizophrenia in particular, reveals how powerful the interpreter may be and how much it wants to succeed in generating reasonable ideas about unreasonable experiences and thoughts that arise out of dysfunctional brain states. As the right hemisphere continues to generate odd, unexplainable images and impressions, the left hemisphere desperately attempts to “interpret” and integrate these aberrations according to some consistent, logical, rule-governing system. Endogenous brain changes, particularly changes in the levels of neurotransmitters such as dopamine, create new circumstances, to which the brain’s interpreter must continually react. That reaction in turn produces perceptions that can become powerful guides for the mental outlook of the patient. An endogenous state that is quickly induced by a change of brain chemistry—such as with a mind-altering drug like LSD—can be fairly easily dismissed as an apparition after the brain’s biochemistry returns to a more normal state. However, if the brain change lasts longer, then the interpretations generated by the altered state of mind become more embellished, and the memories associated with them take on their own life and can become powerful influences on the personal history of the individual. Gazzaniga noted that “crazy thoughts” are manageable for the normal person because they occur as part of some unusual context and thus are easily rejected. On the other hand, continually crazy thoughts, evoked by chronic brain

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dysfunction, become harder to reject. This occurs because of the accumulative effect of one “crazy memory” welcoming other “crazy ideas.” He contends that psychosis results from long-term distortions of reality. The brain’s interpreter tries to bring order to the chaos brought about by biochemical or structural brain abnormalities. As a result of processing erroneous data about self, social relationships, and life circumstances over long periods of time, the brain’s interpreter constructs strange and psychotic theories about reality that become the bizarre images generated by the right hemisphere. Chronic brain dysfunction is not simply the result of the overproduction of the neurotransmitter dopamine. Rather, Gazzaniga (1988) contends that the dopamine abnormality impacts nerve circuits such that they misfire. In turn, the brain’s interpreter creates a specific delusion or set of hallucinations that allow the patient to “make sense” of this phenomenon. He offers a useful description of the overwhelming feelings of vulnerability of individuals entering a psychotic state in contrast to those without this experience. The non-psychotic person’s sense of worth is usually sustained by the positive feedback from social contacts, interactions, and personal relationships. While they may have doubts about the future in known and unknown situations, non-psychotic individuals can cope with such feelings, because life in the past with others has worked out. But what happens as their perception of these automatic rewards changes? Assuming that accurate perceptions reflect brain circuitry that is functional, good feelings are automatically triggered when individuals have contact with a good and trustworthy friend. But, what if seeing that friend did not trigger the response? Gazzaniga believed that this new, negative experience evolves into a state much like chronic psychotic conditions such as Schizophrenia. With their personal reference system at loose ends, because they had trouble producing those automatic rewards, they feel suddenly uncertain and vulnerable (Gazzaniga, 1988, 2006). In this disorienting state, psychotics will view the world through a haze of paranoia. Such a change in neurotransmitter activity in the limbic system, also called the reward-generating system, alters brain circuits, so that pleasant associations and rewards are no longer produced. Accordingly, bizarre thoughts begin to fill this void. Without input of thoughts from the normal reward system, these individuals are in a chronic information vacuum. They search for information from their current environment, but because of their increasing social isolation, little is to be found. As consensual validation decreases, their interpreter creates an alternative reality that accounts for their hallucinations and delusions. Then, intrusive thoughts begin to flood this chronic informational vacuum. As the psychotic individual attempts to cope with these unwanted intrusions, their thinking can become increasingly disordered. The first response can be wild embarrassment, and they are likely to withdraw from social contact. Rather than helping, social isolation further compounds the

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problem. While the brain’s interpreter attempts to deal with imagined sounds and voices, it now must attempt to make sense of them without the steadying influence provided by contact with friends and family. The same can be said about delusions. At times, all persons experience some paranoid thinking. Episodes of overwhelming vulnerability that arise in the absence of a threatening stimulus are usually due to some transitory biochemical balance in the neurocircuitry that the brain’s interpreter easily dismisses as unsubstantiated. But, as it develops into a chronic condition, the brain’s interpreter can create prominent delusions in its attempt to “explain” its neurochemical dysfunction. Psychosis in Two Different Forms Not all psychotic reactions are the same. Adler (2012) and Shulman (1962) identify two variations to psychosis. In the first, psychosis is utilized to impress others and draw them closer. In the second, psychosis is used to withdraw from others and create distance. Given the third law of compensation (i.e., psychic), how the organ inferiority is utilized is instructive in understanding these two forms. Many professionals and laypeople are dismayed to hear that psychosis is used. That is often because they subscribe to belief that individuals only suffer from psychosis and have no part in creating and using it. The reality is that psychosis is not only experienced but also co-created and used (Mosak & Maniacci, 1989; Shulman, 1962; Sperry & Sperry, 2015). A useful analogy is that of a broken leg. No one would deny that a fractured tibia is real and has biological roots, but the choices individuals make can lead them to break their legs, and once broken, the broken legs can be used for many things, including creating mischief in their social worlds. There might have been a congenital weakness in that bone to begin with, but risk-taking behaviors and poor judgment could also have significantly contributed to it as well. While the broken leg analogy is easily understood and accepted, the same logic applied to psychosis is too often rejected. How can psychosis be used? Adler (1956) referred to life as movement, and most importantly for humans, movement in a social sphere. He described four personality types: the ruling type, the getting type, the avoiding type, and the social useful (ideal) type. These types can be plotted along two axes, social interest and degree of activity. A high degree of activity combined with a high amount of social interest is where the socially useful, or ideal, type can be found. These people care about others, show empathy and respect, and are active in their approaches to life. The other three types all have a low degree of social interest, but vary in their amount of activity. The ruling types have low social interest, but high activity. They actively attempt to dominate ­others and create mischief to control people.

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The getting and avoiding types also have low social interest, but unlike the ruling types, they have low degrees of activity. They use relatively passive means to dominate others for different reasons. The getting types attempt to put others into their services, to get them to do things for them. The avoiding types attempt to distance themselves from others to avoid challenges and from further exposing themselves as weak, inadequate, or inferior. Hence, the two main divisions mentioned above. In psychosis associated with Major Depressive Disorder and Bipolar Disorder, the main movement is toward others. As will be detailed below, most of the time, some variation of Adler’s concept of the getting type is found. In psychosis associated with Schizophrenia or Delusional Disorder, the main movement is away from others, which reflects the avoiding type. DSM-5 and Psychosis DSM-5 refers to “psychotic features” as “characterized by delusions, hallucinations, and formal thought disorders” (American Psychiatric Association, 2013, p. 827). The “primary symptoms of psychosis” include “hallucinations, delusions, disorganized speech  .  .  . abnormal psychomotor behavior and negative symptoms, as well as dimensional assessments of depression and mania” (p. 89). While DSM-5 lists eight diagnoses as displaying psychotic features, only four will be described here. They are Major Depressive Disorder with psychotic features, Bipolar Disorder, Schizophrenia, and Delusional Disorders. By definition, all four of these psychotic disorders have significant impact upon an individual’s life. They all greatly increase pain and suffering as well as impairment, more so than the other DSM disorders. Assessment Considerations Assessment occurs along two dimensions: individual partners and the couple relationship. We describe both of these dimensions here and then explore them further in the case conceptualization section that follows. Individual Partner A comprehensive assessment of each partner is essential in order to develop a useful case conceptualization and treatment plan. Identifying the personality dynamics of each partner is a key part of the assessment, case conceptualization, and intervention process. Accordingly, we formally assess the personality dynamics in terms of personality style and disorders. This can be accomplished with a focused, diagnostic interview as well as with the Millon Clinical Multiaxial Inventory (MCMI-IV). The MCMI-IV (Millon, Grossman,  & Millon, 2015) assesses personality styles and disorders as well as

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all four of the psychotic disorders described in this chapter. Over the years, we have been impressed with how these personality dynamics tend to be reflected in the two main forms of psychosis. In the mood disorders, the psychosis appears to serve a specific purpose: to impress people, especially spouses and significant others. The desired impression tends to be slightly different in each. For Major Depressive Disorder, the underlying style of life is typically related to the getting type described earlier. The psychotic features will revolve around a theme of service, attention, and caretaking. For Bipolar Disorder, the getting type is still present (the depressive phase of the disorder), but with the addition of the manic phase—the grandiose, elevated, and expansive mood of the manic— elements of the ruling type are also prevalent. The psychosis will have themes of power, success, narcissism, and exhibitionism. The delusions and hallucinations will serve the purpose of expressing greatness, prestige, and an almost deity-like omnipotence. “Be impressed with me!” will be the message to the partner. In the thought disorders, the psychosis serves a purpose as well: to retreat from or avoid others. Too much contact, intimacy, closeness has been attained, and such close interpersonal contact is threatening. The fears will emerge of being exposed as inferior, inadequate, or weak. Individuals with these disorders are afraid of too much contact for too long because their fantasies of greatness and specialness are too easily challenged. The avoiding type is dominant. For their beliefs to be maintained, distance is required. The over ambition will be thwarted with contact, not validated as with the mood disorders; therefore, the message will be “go away and leave me alone with my private world where life works my way, according to my dreams!” Couple Relationship The couple needs to be assessed as well. The two dimensions involved in assessment are the non-psychotic partner and the relationship itself. Non-psychotic Partner Can a non-psychotic partner cause a psychosis? The question is often asked, even by the partners. The answer is yes, but it is not that simple. The relationship is part of the overall tasks of life. Any of the tasks can be stressful, and sometimes it is the relationship itself that stresses the individual. Many times, however, the non-psychotic partner is caught off guard and not primarily responsible for the issue. Nonetheless, those non-psychotic partners need support, counseling, and assistance as well. Sometimes, they themselves need to change. At other times, they do not need to change, but the way they interact with their partners needs to change. Assessment, once again, is key.

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Relationship Itself As detailed in the first edition of this chapter (Maniacci, 1998), there are two prevailing styles or patterns that clinicians will observed in marriages with a psychotic partner: the psychotic/ controlling pairing and the psychotic/ dependent pairing. The Psychotic/Controlling Couple The controlling partners were typically parentified children in their families of origin. They usually had a dysfunctional parent or sibling they felt responsible for, or saw as such a burden that they decided to become caretakers. The caretaking was sometimes gladly assumed but often was reluctantly selected more out of a sense of necessity than choice. If they did not do it, no one would, and bad things would happen that someone had to clean up, and they were the family custodians. Soon, their significance became tied to their caretaking, even if reluctantly. They displayed a high degree of activity. Many times, they secretly hoped that what they did for others would be done for them, but seldom did they ask or articulate such hopes. When they meet their future psychotic partners, it is typically after those partners have begun to show signs of wear and tear. They can then feel validated and needed; they have significance. Unfortunately, a slippery slope soon emerges. It is a fine line between caretaking and controlling. The non-psychotic partners blur the line between the two, and once that trip begins, it is not easy to go back. Caretaking becomes reminding. Reminding becomes managing. Managing leads to pushing. Pushing devolves into controlling. The psychotic partners soon begin to feel controlled where once they felt protected. The nagging sense that they are not responsible enough, orderly enough, or “good” enough develops. Adler (1956, p. 269) referred to such “care” as “solicitude.” Fascinatingly, he categorized it as a form of aggression. By “taking care” of the psychotic partners, they demonstrated a private sense of hostility, as if they were looking down upon them. This private sense is seldom openly stated, but often it is felt, experienced, by the psychotic partner. As mentioned above, while they tend to lack the linguistic processing that is so important to avoid psychotic reactions, they still feel and intuit the message: they are somehow inferior and need supervision. The Psychotic/Dependent Couple The dependent partners in this pairing classically came from isolated, even inept families of origin. These families were odd, stuck out, and never quite fit in. The children from these families also had a hard time belonging. Their clothes did not match their peers. They did not know or value the typical things other children did, such as the popular movies, music, or sports. They learned that relationships could be painful and disappointing. They hesitated, waiting for others to come to them. Seldom did they. Still,

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they waited, dreamed, and hoped. The lack of experience fostered a notorious inability to differentiate style from substance, posture from poise. They displayed a low degree of activity. When they met their psychotic partners, it was early in the life span cycle, before the first episode, and they were impressed by the grandiosity, creativity, and over ambition. They overlooked or rationalized away the “eccentricities” and “uniqueness” of their partners. They explained them away in a loyal and dedicated manner. They believed rather than questioned. The psychotic partners soon begin to feel smothered. As noted repeatedly, they overvalue distance. Closeness is not the same as admiration. The wanted the latter and started to get too much of the former. They feel crowded and then they pull away. The dependent partner feels abandoned and either pursues or sulks. Many of the psychotic partners report these relationships to be too “sticky.” One client even referred to being with his partner as being caught on “human flypaper.” Eventually, the crisis passes. The psychotic episode resolves. In the psychotic/controlling pairing, the psychosis often serves the purpose of creating space and rebalancing the power. In the psychotic/dependent pairing, the psychosis often serves the purpose of rebalancing the intimacy. The “goldilocks syndrome” is achieved in either the power or intimacy dynamics: what was once too much or too little now becomes just about right. The cost is rather high, though, and cannot be done too many times. Treatment during and immediately after the actively psychotic phase is crucial, but equally as important is the post-psychotic phase. The cycle needs to be changed. Controlling partners need to be less controlling and more caretaking. Dependent partners need to be more loving and less smothering. Case Conceptualization: Individual and Couples Case conceptualization is a method and strategy for obtaining and organizing information about a partner or couple, understanding and explaining maladaptive patterns, focusing treatment, anticipating treatment challenges and roadblocks, and preparing for termination (Sperry, 2010). Central to the case conceptualization, whether it is a conceptualization of one partner or of the relationship itself, referred to as an individual case conceptualization or a couple case conceptualization, pattern is the central and defining feature. Pattern is defined as the predicable, consistent, and self-perpetuating style and manner in which individuals think, feel, act, cope, and defend themselves (Sperry, 2010). Patterns can either be maladaptive or adaptive. Individual Patterns Individual partners tend to bring long-standing problems and maladaptive patterns into their relationships. Their faulty thinking patterns and negative affective reactions can and do wreak havoc on partners’ efforts to enjoy

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intimate contact with the other partner. These individual patterns inevitable reflect each partner’s personality style or personality disorder. As noted in the previous section, the avoiding type and the corresponding avoidant pattern are common among the mood type of psychoses, while the getting type and the corresponding dependent or narcissistic pattern is more common among the thought disorder type of psychoses. Relational Patterns Relational patterns, whether adaptive or maladaptive, tend to be learned by modeling well before the couples meets. Arguably, these patterns reflect the relational patterns of the parents of both partners and appear to be part of the attraction process of the couple. Relational patterns also evolve from the personality patterns of each partner. An effective case conceptualization specifies and explains how these factors operate and explain the couple’s relationship. These maladaptive patterns are evident in every aspects of the relationship: the amount of time spent together, the type of communication, amount, type, and timing of sexual intimacy, how problems and challenges are handled, etc. Not surprisingly, relational patterns have predictable outcomes. Chapter  3 of this book describes the demand/withdraw, demand/ submit, withdraw/withdraw, attack/attack, and reactive demand/withdraw patterns that typify most couples (Sperry, 2019). With regard to the psychotic couple, two patterns seem to predominate: the psychotic/controlling couple and the psychotic/dependent couple. Both were described previously described in the Assessment section of this chapter. It is useful to add that schizophrenic individuals are unlikely to have satisfying intimate relationships and seldom marry. When they do pair off, Schizophrenia may first appear after marriage, and rarely before, unless there is a long period of remission between episodes. Typically, this is not the case with Delusional Disorder, wherein individuals tend to have (somewhat) satisfying relationships prior to the onset of the disorder. In contrast are the attraction and marital dynamics in the two mood disorders. In both, pairing off and dating is typically not a problem. Bipolar Disorder and Major Depressive symptoms wax and wane enough to allow frequent periods of stabilization, and individuals’ social skills are far better developed than those with Schizophrenia (Rasmussen & Aleksandrof, 2015). Marriage and long-term commitment, however, can be problematic, especially when psychotic features periodically emerge. In the mood disorders, the partners are initially impressed. During the initial phase of mania, known as hypomania, the individuals can be very productive, expansive, and impressive. A lot gets done and ideas flow freely. It will not last. Hypomania shifts to full blown mania (sometimes referred to

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as “frank mania”), and with psychotic features, ideas are no longer creative; they are labeled as “crazy,” “weird,” or “nuts.” Disapproval rises and the individuals panic as their frantic attempts to impress backfire. As the mood shifts towards the depressive phase, full blown mania shifts to irritable mania. The feedback loop is negative and the individuals are mad at their partners for not seeing their brilliance or heroic efforts at mastery. Violence and dangerous aggression often emerge as an attempt to force others or life to yield. Partners pull away, scared and confused. In Major Depressive Disorder with psychotic features, the panic emerges as the individuals anticipate abandonment. For a long time, they have trained themselves to be charming and appealing. They have relied upon others to help them achieve their goals, if not get the goals for them. As they become psychotic, delusions of death, unrealistic guilt, and self-flagellation appear. Being the worst person on the planet who is destined to be alone, to die, to cause great harm, are regular themes. Everything is ruined and they cannot handle it anymore; someone must step in. Someone does, and the symptoms abate. Unless the partners are terrified, overwhelmed, and burnt out. The negative feedback loop creates more distance, not less, and individuals often double down and dig in their heels. With the thought disorders, partners are genuinely terrified. Ideas of reference, hallucinations, thought broadcasting, and insertion are almost universally rejected, and the distance is not initially granted. The paradox emerges that though initially intended to distance others, the bizarreness of the symptoms may initially lead loved ones to get closer and be more attentive. Unfortunately, it seldom works, since the symptoms will increase until the message is more clearly heard: go away! Partners are likely to be confused and feel victimized. If they do retreat, harm may emerge not only to their psychotic partners but also to careers, family members, and others. If they do not retreat, the situation may worsen. They often feel they are “damned if they do, and damned if they don’t.” In both types of psychosis, relationships can be and often are wrecked. The brains and bodies of psychotic individuals are increasingly damaged with each episode, but so are relationships, careers, and families. Intervention is required, but in the current age of professional territoriality, such individuals are typically under treated. Either the emphasis is too much upon medications at the expense of psychosocial interventions, or the opposite: too much time is spent with psychological interventions that may be effective but slow and therefore allow risk to increase. Even within psychosocial modalities, individual therapists do not utilize couple and family interventions early or effectively enough, and couple and family therapists do not engage in individual treatment to the degree needed. Psychotic episodes can be harmful and are emergency situations. Multidisciplinary approaches and integrative concepts are what is needed.

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Clergy, lawyers, and financial planners can be extremely useful in the treatment and repair of the damage. Cultural Considerations An important component of the case conceptualization is the cultural formulation. A clinically useful cultural formulation specifies key cultural considerations such as cultural identity, level of acculturation, and explanatory model or cultural explanation (Sperry, 2015). The DSM-5 is also sensitive to cultural considerations that can be misunderstood as psychosis. Each diagnosis has a section labeled culture-related diagnostic issues. “In certain cultures, distress may take the form of hallucinations or pseudo-hallucinations and overvalued ideas that may present clinically similar to true psychosis but are normative to the patient’s subgroup” (American Psychiatric Association, 2013, p. 103). In addition:

C

ultural and socioeconomic factors must be considered, particularly when the individual and the clinician do not share the same cultural and economic background. Ideas that appear to be delusional in one culture (e.g., witchcraft) may be commonly held in another. (p. 108)

Much to their commendation and almost universally unappreciated, DSM-5 has an entire appendix entitled, “Glossary of Cultural Concepts of Distress” (pp. 833–837). It is a list of concepts not common in Western culture that can be mistaken for disorders. Many of them are easily confused with psychotic reactions such as “Maladi moun” (p. 835). It is a condition native to Haitian communities and literally translates as “sent sickness.” It occurs when “interpersonal envy and malice” cause people to send illness to someone. It can be misdiagnosed as Delusional Disorder, persecutory type, or Schizophrenia. Of the nine syndromes defined in the appendix, seven of them have some similarities to symptoms discussed in this chapter. It is crucial to consider these nine syndromes, and numerous others, before too quickly assuming a “psychotic reaction” is a true psychotic episode. DSM-5 has an appendix labeled “Cultural Formulation” (pp.  749–759) and has a “Cultural Formulation Interview (CFI)” form (American Psychiatric Association, 2013, pp. 752–757) interviewers can use that comes in two varieties: for patients and for informants. Finally, in working with the psychotic couple, clinicians should not discount the influence of a non-psychotic partner, which can be an invaluable resource for normalizing the disordered partner’s reactions and presentations for uninformed clinicians. Furthermore, for it to be optimally useful, clinicians would do well for their couple case

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conceptualizations to be informed by the elements of culture elaborated in DSM-5. Case Example: Mike and Olivia Two cases will be presented. One will emphasize long-term treatment with a couple whose husband has Bipolar Disorder with psychotic features. The other will explore some short-term work with a couple whose wife was diagnosed with Schizophrenia with paranoid features. Background: DSM-5 and Cultural Considerations Mike was of East Indian ancestry. His parents had moved here when he was 2 years old. He was the eldest of three with a younger brother and sister. Success was the mantra, motto, and motivation for all things. He was a brilliant youngster who easily achieved his goals, but was “nervous” and “jumpy.” Then, he was diagnosed with Attention-Deficit/Hyperactivity Disorder, combined type. He seemed to respond to the stimulant medication, but by his own admission, he “liked it too much.” By college, he was using it, and cocaine, and a lot of marijuana to “take the edge off.” That is where he met Olivia. She too was a recent immigrant from India. She was also an oldest born (of four) who was the “little parent” of some rather “rambunctious” siblings. She was an education major. He was studying business and finance. Both were at the top of their class and even competed with each other for valedictorian. Their courtship was formal but fast. They married shortly after college, and Olivia began to notice some “peculiar things.” He could be “gone” a lot and could be both brilliant and very irritable. After a drinking binge with some former college buddies, he flew to Las Vegas and won several thousand dollars in blackjack. He did this over a 36-hour period without checking with her. It was then that he was diagnosed as Bipolar Disorder with psychotic features. Mike and Olivia “had a talk” and sorted things out. Nothing like this occurred again for about two years. They sought treatment shortly after that calm period. Mike began spending a great deal on his investment business. It was successful, but his expenses were getting excessive. He was caught with open alcohol in his car by a police officer after leaving a strip club. Olivia was devastated. He explained how he was doing “research” for work, trying to interview the patrons and young ladies in order to better “understand” his clientele who were young, powerful men who frequented such establishments. At first Olivia was convinced that he was simply lying to get out of trouble, yet soon it became apparent that he was sincere. Over the next few days, she discovered how “bizarre” his explanations—and actual behavior—had become. His parents were called and he was hospitalized and placed on

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lithium, a mood stabilizer, and diagnosed with bipolar I disorder with psychotic features. The extent of his psychotic behavior became clearer each day. He had been keeping journals documenting his grand plans for world domination, starting a new religion, and becoming the next “Bill Gates.” Olivia was terrified, and his parents were baffled. Assessment Considerations Adlerian clinicians use early recollections as a projective assessment technique (Carlson et  al., 2006; Powers  & Griffith, 1987; Shulman  & Mosak, 1988). This was his earliest memory: Age 4: I was going to school, a year early, and my parents dropped me off at the front door. I introduced myself to the teacher and handed her some ideas I had jotted on paper for the class. She was surprised, but gave me a hug. Most vivid part: she hugged me when I gave her the paper. Feeling: proud, this would be fun. Olivia’s earliest recollection was the following: Age 5: Mom was ill today. I got everyone going by helping make lunches and getting them out to school. As I was leaving myself, I checked in with her and she said, “thanks, what would I do without you.” Most vivid part: making the lunches. Feeling: proud, they all listened to me for once! The themes are clear. Mike is a mover and shaker. He started school early, so he expects to be faster than everyone else. He asserts himself and others give him affection for it. He “gets” attention by “ruling” and telling others what to do. Olivia is also in the “ruling” spectrum, but notice a crucial difference. When Mother compliments her, Olivia does not focus upon that but rather the fact that “they all listened to me.” Case Conceptualization: Individual and Couple In terms of their relational pattern, Mike and Olivia’s relationship was characterized by psychotic/controlling pairing. Mike had a combination of ruling and getting types. Olivia was clearly in the ruling category. He wanted to be taken care of as reward for his achievements, and she loved to take care of him, “if and when he behaved himself.” She scolded, admonished, and pampered him, much as his parents had. He achieved a great deal at a young age and continued to show great promise, but he had trouble setting limits on himself. He was drawn to drugs that helped him achieve a sense of power and allowed him to push himself harder.

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Treatment Considerations Outpatient treatment involved a combination of individual and couple therapy. Monthly, a psychiatrist joined the individual sessions for multiple therapy all the while closely monitoring the medication. Alcoholics Anonymous was tried several times, but Mike would never stay for long. When Mike insists that he is at the strip club for research to help his business, the meaning is this: I need more information. The purpose? He lacks knowledge, he feels he is lost. Remember his early recollection. He showed up at school with a list and a plan. He was four years old. He should be ahead of the crowd and know what to do before everyone else. With the strip club, he was implicitly acknowledging something: he was lost, he had no plan. He felt he was out of touch with his young clientele, and that panicked him. Olivia scolded him, understandably, until she realized how out of touch he was. He was psychotic. The response that won him over in therapy was when the clinician responded to him by saying, “Your family and business mean so much to you. You do research and keep working while others are playing. Thank you for being so dedicated.” He burst into tears, as did Olivia. He was still bipolar, but for the next several days, he was no longer psychotic. Efforts were directed to helping him, and the couple, find ways to balance his work with home life, and to keep him up to date with the changing demographics of his clientele. He calmed down and the marriage stabilized. Clinical Outcome Couples work was challenging. They both challenged the therapist (and psychiatrist) regularly. They researched the therapist and read (some of) his publications. After two and a half years of therapy, Mike is stable and has decided to “wean” himself off his medication. The psychiatrist is patiently following him but skeptical. There have been no other psychotic episodes. Case Example: Barbara and Danny Danny was sent to treatment by his wife, Barbara, who was in individual treatment with a colleague of one of the authors (MM). He was hesitant but compliant. He had previously “auditioned” several other therapists at his wife’s request and settled here. Barbara had been married for several years, having married at age 19. It was a tumultuous relationship with a history of fighting and verbally attacking her spouse. After almost 25 years, he left, leaving her with three children. She lived without him and raised the children “as best she could.” When she met Danny five years ago, he too was divorced with four grown children. She has a master’s degree in nursing and was a nurse practitioner. He was a welder with a high school education.

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Barbara is basically distanced from her family. Two of her three children wanted “nothing to do with her” anymore. The third lived out of state and only checked in occasionally. Because of an inheritance, she was independently wealthy and retired. She took care of Danny, and he “retired” to marry her and spend time as her “traveling companion.” Within the last two years, he has found her “challenging.” He is baffled by her requests. She frequently calls him to “check out the house.” Someone regularly “comes in and moves” her belongings. She knows people are watching the house and waiting for them to leave so they can “mess with her stuff.” These people have “taken” her children away from her by turning them against her. Danny’s children, as well, have been “turned” and have little to do with her. He tries to be diplomatic and “explain things” to her but she will have “none of it.” She has recently begun to believe he is “part of them.” He reportedly “rages” at her and threatens her with his “wild eyes” and “violent gestures with his hands.” In the last two years, he has been exiled to a hotel for weeks at a time, and can only return when she calls. The latest condition for his return is he gets individual therapy for his “rages and wild eyes.” They tried couple therapy once before, but it was a “disaster.” That therapist confronted her, “got in her face,” and the session ended with a verbal explosion by Barbara and a vow to never return. She never went back. Danny wanted individual treatment (because she said he did) and only on occasion would she check in with his treatment. DSM-5 Diagnostic and Cultural Considerations Barbara met criteria for the diagnosis of Schizophrenia with paranoid features. Both identified as middle-class whites who were highly acculturated and denied any cultural distress. Barbara’s explanatory model was that her condition resulted from “bad genes” and “too much stress.” She reported that her maternal aunt was diagnosed as a schizophrenic and hospitalized off and on in all the time Barbara knew her. Danny was diagnosed with a narcissistic style, meaning he met only four of the five criteria needed for Narcissistic Personality Disorder. His explanatory model was that he learned from his father and that he was entitled to have special favors and treatment from others. Assessment Considerations Danny had completed six individual sessions. During this time, personality dynamics were elicited in the course of a Life Style Assessment Carlson et al. (2006). Barbara has refused the assessment for herself but was fascinated when she learned the results of Danny’s personality assessment. He was the youngest of four and the “baby” who was pampered by his overprotective

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mother. He had bad allergies that caused him problems as a child, but he admitted to having “used” them to get out of school when he wanted time off. His earliest recollection was: Age 6: I didn’t want to go to school. I rolled over in bed and told mom “I’m sick, I’m tired, oh please!” and she rubbed my cheeks and said, “okay.” She brought me some cookies and milk and sat on the bed while I ate, reading me a story. Most vivid part: the warm cookies tasted so good. Feeling: warm, safe, loved. The interpretation of this early recollection was that he “gets” his way by whining and playing “sick.” Women are supposed to yield to that and love him. Fortunately for him, Barbara loves taking care and pampering him. Recall that she was a trained and experienced nurse. Case Conceptualization: Individual and Couples In terms of their relational pattern, Danny and Barbara’s relationship was characterized by the psychotic/dependent pattern. Danny had a combination of getting and ruling types. Barbara had a combination of the avoiding and ruling types. Treatment Considerations The basic treatment strategy for this couple was that symptoms are important and must be taken seriously and addressed. Nonetheless, core issues are the focus, not simply symptoms. Chasing symptoms can be exhausting and frustrating. Accordingly, treatment was done calmly and supportively, and despite her paranoid features, Barbara felt understood. Interventions that supported this basic strategy were: Medication Barbara was prescribed antipsychotic medication by her psychiatrist. The purpose was calm her “nerves,” but after several months she has stated that she may discontinue it. She will not report what she is taking, only that she is and it “helps.” Furthermore, Barbara refuses to give permission to speak to her therapist but reports that he feels she can “trust me.” Relaxation Training Deep breathing, relaxation training, and “time outs” can do wonders. Often couples get in vicious cycles that escalate. Understanding what is known as DPA—diffuse physiological arousal—and how to short circuit the flood of norepinephrine frequently experienced during panic can seem to produce miracles (Gottman, 1999; Gottman  & Gottman, 2015). A  safe rule is this:

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whenever they find themselves saying the same thing three times, they need a calming space for a time out. When they agree to such rules, conflict remains as conflict, not fights, and things do not escalate out of control. The “rule of three” helps at such times. During these heated exchanges with psychotic individuals, the partner is taught to . . . 1. Leave the conversation . . . 2. Leave the room . . . 3. Leave the home. Try redirecting the conversation. If that does not work, ask for a time out and leave the room until things calm down. If that fails, leave the home, go for a walk, and try again later. Interpretation When used wisely, this can help. The symptoms in psychosis mirror the issues in the Life Style Assessment, particularly the early recollections (Mosak & Fletcher, 1973). In fact, the hallucinations and delusions often are fantasized versions of the themes in the early recollections. A  model for translating psychotic verbalizations has been discussed elsewhere, including in the first edition of this chapter (Maniacci, 1998; Mosak & Maniacci, 1989). The process involves distinguishing meaning from purpose and response. The meaning of the symptom is idiographic. It is a symbolic statement designed to communicate something, if people can translate it. Meaning is different from purpose. Purpose entails goals, sometimes long-term, sometimes short-term. In other words, sometimes the symptom or verbalization is indicative of something the individuals want in the long-term, such as power, respect, or success. Sometimes the purpose is very short-term and designed to achieve an immediate goal, such as distance or attention. The response provided by the clinician should be directed to the purpose, and not primarily the meaning. With skill, the non-psychotic partners are taught to do this as well, and it helps. When Barbara claims, “People are moving my stuff,” the meaning is clear: she feels out of control. “Stuff ” that is important to her is being taken from her (e.g., her children). To focus on the “loss” of her children is too painful for her, so she symbolically attempts to process the issue by speaking “schizophrenese” (Mosak & Maniacci, 1989, p. 465). The purpose of such a statement? She wants her stuff left alone, or to get it back. She wants control again. The response, both by the clinician and her husband, is something like this: “I know, it is so hard to lose important stuff. Let’s make sure you never lose anything else again.” When Danny tried to “reason” with her and insist nothing was taken, Barbara felt misunderstood and therefore “turned up the volume,” so to speak. She became more delusional. When the clinician, and

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her husband, respond by saying they will help her regain her “stuff ” or at least not lose any more of it, she feels understood and stops speaking in symbolic language; for the moment, she is rational again and says “thanks” as she tears up. She is assisted in regaining control. The schizophrenic disorder may still be present, but the psychosis is resolved for a while. Clinical Outcome The couple has come in for three sessions despite her saying she will not do couples treatment. How did she manage to come in despite her protests? She was asked to be a “co-therapist” and assist in his treatment. She was fascinated by this role and agreed to participate. Despite the fact that he continued to live at a hotel, they report that the marriage is “solid” again because she is learning how to care for him without pampering him. He is learning how to respond in a supportive way to her requests without fighting, while still not validating her delusions and hallucinations. Conclusion Couples work with psychotic individuals can be challenging. Biological, cultural, vocational, psychological, and medical issues often intertwine with substance abuse, interpersonal conflict, financial jeopardy, and outright panic. Many cooks can be handling the pot, and sometimes they do not work together smoothly. They need to, or else progress is difficult. Clinicians need to be sensitive to many dynamics. Even in cases where it is a culture-related syndrome, the spouses need to be dealt with, for they may not fully understand the issues if they are not from the same background. The two types of psychosis—depression/Bipolar Disorder vs. Schizophrenia/Delusional Disorder—need to be clearly differentiated. Clinicians and partners need to know if the symptoms are asking for closeness and admiration or distance and relief. To treat them as the same causes considerably more grief. The symbolic language needs to be eliminated and common-sense language taught to the individuals. Their verbal processing needs to be facilitated. When they use common sense, they no longer need their symptoms. Perhaps their brains heal, or they do not get worse. The research is still unclear. Finally, clinicians and couples need to understand that many marriages can be saved, but some cannot be—or should not be. For the couples to stay together, the cycle of psychosis and disorder may only get worse. Everyone might be better with more distance. In some select cases, to live together full time may never work. They may not need a divorce, but periodic stays at a hotel or with a friend or relative may be enough, with the treatment, to keep things stable and even satisfactory. Some couples may have to divorce, if that

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is what the psychotic individual eventually needs, in order to maintain stability and break the pattern of psychosis. In those cases, time and experience will tell. References Adler, A. (1956). The Individual Psychology of Alfred Adler: A systematic presentation in selections from his writings (H. L. Ansbacher & R. R. Ansbacher, Eds.). New York, NY: Basic Books. Adler, A. (2012). Melancholia and paranoia. In J. Carlson & M. P. Maniacci (Eds.), Alfred Adler revisited (pp. 266–279). New York, NY: Routledge. (Original work published 1914). American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author. Anonymous. (1994). First-person account: Life with a mentally ill spouse. Schizophrenia Bulletin, 1, 227–229. Carlson, J., & Maniacci, M. P. (Eds.). (2012). Alfred Adler revisited. New York, NY: Routledge. Carlson, J., Watts, R. E., & Maniacci, M. (2006). Adlerian therapy: Theory and practice. Washington, DC: American Psychological Association. Dreikurs, R. (1967). Psychodynamics, psychotherapy and counseling. Chicago, IL: Alfred Adler Institute. Gazzaniga, M. (1988). Mind matters: How mind and body interact to create our conscious lives. Boston, MA: Houghton-Mifflin. Gazzaniga, M. (2006). The ethical brain: The science of our moral dilemmas. New York, NY: Harper Perennial. Gazzaniga, M., Ivry, R., & Mangun, G. (2008). Cognitive neuroscience: The biology of the mind (3rd ed.). New York, NY: Norton. Gottman, J. M. (1999). The marriage clinic: A scientifically based marital therapy. New York, NY: W. W. Norton & Company. Gottman, J. S., & Gottman, J. M. (2015). 10 principles for doing effective couples therapy. New York, NY: W. W. Norton & Company. Maniacci, M. P. (1998). The psychotic couple. In J. Carlson & L. Sperry (Eds.), The disordered couple (pp. 57–81). Bristol, PA: Brunner/Mazel. Maniacci, M. P., & Carlson, J. (1991). A model for Adlerian family interventions with the chronically mentally ill. American Journal of Family Therapy, 19, 237–249. Maniacci, M. P., & Sackett-Maniacci, L. (2019). Adlerian psychotherapy. In D. Wedding & R. Corsini (Eds.), Current psychotherapies (11th ed.). Belmont, CA: Cengage. Maniacci, M. P., & Sperry, L. (2015). Neurocognitive disorders. In L. Sperry, J. Carlson, J. D. Sauerheber, & J. Sperry (Eds.), Psychopathology and psychotherapy: DSM-5 diagnosis, case conceptualization, and treatment (3rd ed., pp. 335–355). New York, NY: Routledge. Millon, T., Grossman, S., & Millon, C. (2015). MCMI-IV manual. Upper Saddle River, NJ: Pearson. Mosak, H. H., & Fletcher, S. J. (1973). Purposes of delusions and hallucinations. Journal of Individual Psychology, 29, 176–181.

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Mosak, H. H., & Maniacci, M. P. (1989). An approach to the understanding of “schizophrenese”. Individual Psychology: The Journal of Adlerian Theory, Research  & Practice, 45, 465-472. Powers, R. L., & Griffith, J. (1987). Understanding life-style: The psycho-clarity process. Chicago, IL: Americas Institute of Adlerian Studies. Rasmussen, P. R.,  & Aleksandrof, D. (2015). Depression and bipolar disorders. In L. Sperry, J. Carlson, J. D. Sauerheber,  & J. Sperry (Eds.), Psychopathology and psychotherapy: DSM-5 diagnosis, case conceptualization and treatment (3rd ed., pp. 95–122). New York, NY: Routledge. Shulman, B. H. (1962). The meaning of people to the schizophrenic versus the manicdepressive. Journal of Individual Psychology, 18, 151–156. Shulman, B. H., & Mosak, H. H. (1988). Manual for life style assessment. Muncie, IN: Accelerated Development. Sperry, L. (2010). Core competencies in counseling and psychotherapy: Becoming a highly competent and effective therapist. New York, NY: Routledge. Sperry, L. (2015). Diagnosis, case conceptualization, culture, and treatment. In L. Sperry, J. Carlson, J. Duba-Sauerheber, & J. Sperry (Eds.). Psychopathology and psychotherapy: DSM-5 diagnosis, case conceptualization and treatment (3rd ed., pp. 1–14). New York, NY: Routledge. Sperry, L. (2019). Assessment and case conceptualization with couples and families. In L. Sperry (Ed.), Couple and family assessment: Contemporary and cutting-edge strategies (3rd ed.). New York, NY: Routledge. Sperry, L., & Sperry, J. (2015). Schizophrenia spectrum and other psychotic disorders. In L. Sperry, J. Carlson, J. D. Sauerheber & J. Sperry (Eds.), Psychopathology and psychotherapy: DSM-5 diagnosis, case conceptualization and treatment (3rd ed., pp. 177–204). New York, NY: Routledge. Winefield, H. R., & Harvey, E. J. (1994). Needs of family caregivers in chronic schizophrenia. Schizophrenia Bulletin, 3, 557–566.

6 THE ANXIOUS COUPLE Katie L. Springfield and Rosa M. Macklin-Hinkle

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nxiety, while generally viewed and conceptualized as problematic and interfering, is an evolutionary strategy for survival. Anxious experiences are designed to aid in predicting, analyzing, and planning for possible forms of risk and/or danger. The ultimate purpose for anxiety is to motivate and energize an individual into preparation and action (Bateson, Brilot, & Nettle, 2011). Anxiety, however, becomes problematic when it is no longer appropriate or adaptive. Experiences of panic, restlessness, rumination, and irritability lose their utility when situations and circumstances no longer pose a threat to the mental, physical, and social well-being of an individual. Despite this lack of evolutionary function, anxiety remains a prominent and detrimental experience with universal prevalence (Bateson et al., 2011). Anxiety is one of the most common mental illnesses that result in significant individual, occupational, social, and financial consequences (Bateson et al., 2011). According to the Anxiety and Depression Association of America (ADAA), it is estimated nearly 40 million adults, or roughly 18% of the adult U.S. population, experience symptoms related to anxiety (ADAA, 2016; Bateson et  al., 2011). Anxiety is often chronic and deleterious to an individual’s general sense of self, self-esteem, efficacy, and worth. It has the power to derail logic and foster despair and overarching dread. Additionally, it can significantly impact one’s ability develop and maintain healthy romantic relationships. Overview: Theory and Research on the Anxious Couple The following section will discuss literature regarding anxiety disorders in a broader sense, with specific anxiety disorders being highlighted throughout. The impact of these disorders on romantic relationships will be explored

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later in this chapter. Treatment and assessment recommendations, as well as an illustrative case example, will also be provided. Providing a thorough literature review about each anxiety-related disorder is outside the scope of this discussion. Attachment Styles and Anxiety Attachment, like anxiety, is a biologically adaptive system designed to motivate survival through seeking and maintaining closeness with caregivers (Doron et al., 2011). This neurobiological system is comprised of the way in which people relate, perceive, and understand themselves in relation to others, playing a significant role in the functioning of adults and their intimate relationships. The development of a healthy and secure attachment style begins as early as infancy with effects that are felt and observable throughout adulthood (Brumariu, Obsuth, & Lyons-Ruth, 2013; Cusimano & Riggs, 2013; Marganska, Gallagher, & Miranda, 2013; Schimmenti & Bifulco, 2013). Attachment styles are founded in the experiences with and bonds to early caregivers; through these attachments, an individual learns to form assumptions/ideas about themselves, how to relate to others, and how to identify and regulate affective experiences. Attachment styles have been found to influence levels of anxiety experienced by individuals in both childhood and adulthood. For example, a child will respond to strong emotions through the messages they have received from primary caregivers and others about who they are, the way people react to their emotional pleas, and the way they have seen others manage emotional content. These early patterns, while not set in stone, are often pervasive and difficult to change as time progresses (Marganska et al., 2013). As such, it is clear that early attachment styles can, and do, impact later relationships, including those with intimate partners. Exploring early attachment styles can help clients and clinicians better understand relationship styles and interactions, make meaning of these interactions, and form interventions based on each partner’s attachment style and needs. When considering adult attachment style, a four-category model has been developed, which is comprised of secure, preoccupied, fearful avoidant, and dismissive avoidant (Brumariu et  al., 2013; Cusimano  & Riggs, 2013; Marganska et al., 2013; Schimmenti & Bifulco, 2013). A secure attachment style is evidenced by a general positive view of the self and other and effective emotional regulation; those with a secure attachment are at lower risk of developing pathological symptoms. Insecure attachment, conversely, is characterized by inconsistent and/or negative views of self and others, diminished tolerance for stress and frustration, and increased mental illness (Cusimano & Riggs, 2013). In terms of adult attachment, secure attachment offers the opportunity for being comfortable and feeling worthy of being loved and close with others. Preoccupied attachment, or anxious ambivalent, is evident when an

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individual exhibits generally poor views of themselves but tends to idealize or only view the positive in those around them. These individuals tend to hold the belief they are unworthy of care and consideration from others, but acceptance and commitment are desired and pursued most vigorously (Marganska et al., 2013). Fearful avoidant attachment, however, is evident when an individual views both themselves and others as negative and sources of rejection and pain. These attachment patterns become clear depending on a person’s response to closeness; those with more anxious attachment tendencies dread abandonment, whereas those who demonstrate avoidant attachment are threatened by intimacy (Brumariu et al., 2013; Cusimano & Riggs, 2013; Marganska et al., 2013; Schimmenti & Bifulco, 2013). The ability to tolerate and manage affective stressors in an appropriate and effective manner stems from interpersonal experiences and the messages one has received over one’s lifetime. Identifying an individual’s and, subsequently, a couple’s attachment style will influence not only the individual’s ability to manage and function during distress but also their ability to navigate and seek social connection. Those individuals functioning from an anxious/insecure attachment style are likely to experience lower self-esteem and social competence and increased feelings of loneliness, which contribute to difficulties within interpersonal relationships, particularly those of a romantic nature (Marganska et al., 2013). Attachment and Psychopathology The link between attachment style and mental illness and wellness has also been researched extensively (Brumariu et al., 2013; Cusimano & Riggs, 2013; Marganska et al., 2013; Schimmenti & Bifulco, 2013). A direct correlation has been found between adult attachment style and the development of anxiety-related disorders, particularly generalized anxiety disorder (Marganska et al., 2013). Insecure attachment styles, preoccupied and fearful especially, are particularly predictive of the development of an anxiety disorder. The presence of antipathy, or overt hostility, within the parent–child relationship appears to be especially predictive of anxiety disorders (Schimmenti & Bifulco, 2013). Insecure attachment styles, or negative experiences with caregivers, coupled with poor emotional regulation further contribute to the chances of anxious experiences. Cusimano and Riggs (2013) similarly explored the relationship between interpersonal functioning, romantic attachment, and psychological functioning. According to their findings, adults with insecure attachment styles are more likely to experience anxious symptoms in general and social anxiety, and these anxious symptoms contribute to fears of abandonment, greater interpersonal dependency, and emotional dysregulation. Furthermore, the ability to seek and give care, to feel comfortable alone, and to negotiate interpersonal situations were negatively impacted by the presence of an insecure attachment style and anxious symptoms (Cusimano & Riggs, 2013).

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Generalized anxiety disorder and Panic Disorder appear to be strongly associated with the presence of attachment insecurities. The connection between OCD and attachment begins with thoughts or events that test selfworth while an individual initiates repair attempts to feel better. The presence of insecure and anxious attachment tendencies provides the groundwork for self-doubt and deprecation, which may foster the emergence of OCD symptomology. Lacking the experience of consistent and nurturing care during infancy and childhood hinders the development of effective coping and emotional regulation, thereby increasing chances of obsessive–compulsive tendencies (Doron et al., 2011). The role of attachment appears to also play a part in the onset and perpetuation of social anxiety disorder (Eng, Heimberg, Hart, Schneier, & Liebowitz, 2001). The very nature of social anxiety is focused on relational functioning. This type of anxiety is focused on an intense fear of embarrassment or humiliation during social and/or performance interactions (Eng et al., 2001). Individuals diagnosed with social anxiety disorder consistently presented with anxious-preoccupied attachment style. Relational tendencies, such as less comfort with intimate relationships, difficulty trusting, and greater fear of rejection and abandonment, were also prominent within those influenced by an insecure attachment style (Eng et al., 2001). Somewhat unique to this population is the tendency to withdraw, rather than pursue, as a result of relational and attachment fears. In general, the more insecurely attached an individual is, the more anxiety they are vulnerable to experiencing (Brumariu et al., 2013; Cusimano & Riggs, 2013; Doron et al., 2011; Eng et al., 2001; Marganska et al., 2013; Schimmenti & Bifulco, 2013). Anxiety and Couples Those who have committed to a relationship with someone who has been diagnosed with anxiety feels and experiences the ripple of fear often present for the person who has been identified as struggling with the illness (Zaider, Heimberg, & Iida, 2010). The impact of anxiety on a couple is felt by both significantly, as adults are challenged with having to express and manage distress within their intimate relationships. The primary source of support often shifts from parent to partner, and one’s relational attachment needs to be carried through childhood to influence the progression of relational anxiety and clinically anxious symptomology (Zaider et al., 2010). Individuals with an anxiety disorder do not often do this well and instead experience high levels of anxiety that negatively impact their romantic relationships. Because the presence of anxiety is acutely present within the “anxious” couple, research has explored the effects on the relational dyad. Studies have indicated that anxiety in one partner will often lead to perceptions of poor marital quality by both partners (Zaider et al., 2010). On the other hand, martial dissatisfaction and dysfunction are significant predictors of the onset of

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an anxiety disorder, particularly Generalized Anxiety Disorder, Social Anxiety Disorder, and Post-Traumatic Stress Disorder (Pietromonaco, DeBuse, & Powers, 2013; Zaider et al., 2010). Whether anxiety is the source or result of marital dissatisfaction, the behaviors often present within anxious functioning works in accordance with the progression of ongoing anxiety and frustration within the couple. Anxiety symptoms from the anxiety-disordered partner may be displayed without his/her awareness in order to gain closeness, care, and reassurance; in most situations, however, these behaviors work against the anxious individual and the partnership as a whole (Pietromonaco et al.; 2013; Zaider et al., 2010). In some situations, the presence of anxiety within a relationship achieves the goal of increased closeness and support. Research demonstrates supportive relationships can sometimes perpetuate anxiety symptoms because its primary goal has been met (Zaider et al., 2010). Although this view of an anxious couple may seem inherently accusatory of the “identified patient,” it is important to emphasize that the perpetuation of anxiety-driven relationship strategies are not often employed with purposeful choice. Instead, they stem from the attachment style of the individual and work toward social survival. Even though some couples are able to function somewhat effectively within this relational dance, the chances of marital/partnership dissatisfaction remain as the couple can only withstand the constant pull of one partner and give of the other partner for so long (Zaider et al., 2010). Impact on the Significant Other There are a number of adverse interpersonal and intrapersonal effects for the non-anxiety disordered partner. Emotional contagion is a term for referring to circumstances when an individual’s mood is impacted and shaped by the mood of someone else. According to the literature, displays of anxious behaviors and/or symptoms often result in increased feelings of rejection, devaluation, and overall distress in the partner (Zaider et al., 2010). In partners and family members of people diagnosed with OCD, increased levels of distress appear to be associated with felt pressure to accommodate obsessions and compulsions, and their critique of their partner (Pietromonaco et al., 2013; Zaider et al., 2010). Anxiety stressors appear to impact the significant other on a physiological level as well. Pietromonaco and associates (2013) found significantly higher cortisol levels of individuals whose partners had an anxiety disorder. Over time, persistent elevated cortisol levels result in deteriorating physiological and mental functioning. Anxiety Due to Situation and Circumstance Genetic predisposition and attachment often play prominent parts in the presence of anxiety within a romantic/intimate relationship. Situation and circumstance, however, may also play a leading role in the development and

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progression of anxiety disorders within a couple. Certain life events, such as loss, infidelity, financial stressors, medical and legal concerns, and separations, are all possible triggers for the development of relational clinical anxiety. Infertility issues and military deployment appear particularly noteworthy when considering the anxious couple (Klemetti, Raitanen, Sihvo, Saarno, & Koponen, 2010; Mansfield et al., 2010). As such, it is important to be able to properly identify the anxietyprovoking circumstances and symptoms expressed within the couple to effectively diagnose and treat anxiety-disordered couples. DSM-5 and the Anxious Couple The DSM-5 utilizes a categorical approach to diagnosis, and clinicians must determine which subset of characteristics clients meet from a larger list of diagnostic criteria. This is particularly notable for the diagnoses included in this chapter. Many of the diagnoses offer specifiers that allow the clinician to convey how the particular client is expressing symptoms. Clinicians also need to consider how culture plays a role in the expression and presentation of symptoms. Generalized anxiety disorder Individuals with generalized anxiety disorder present with excessive and difficult to control anxiety and worry, more days than not, with symptoms present for at least six months. The anxiety and worry are accompanied by a minimum of three of the following six symptoms: restlessness, fatigue, irritability, muscle tension, difficulty concentrating, and/or sleep disturbance (American Psychiatric Association, 2013). Social Anxiety Disorder Individuals with this disorder display marked fear or anxiety about social situations, in which the individual may be exposed to scrutiny. The individual fears their behavior will be negatively evaluated, and social situations evoke fear or anxiety. Social situations are thereby avoided or endured with much discomfort and anxiety. The individual experiences fear or anxiety that is out of proportion with the actual threat posed by the social situation (American Psychiatric Association, 2013). Panic Disorder Panic Disorder is characterized by recurrent, unexpected panic attacks, which the individual tries to avoid by engaging in maladaptive avoidance behaviors. Individuals also experience persistent worry about additional panic attacks. Symptoms onset quickly and peak within minutes and include (but are not limited to) heart palpitations, sweating, trembling, shaking, shortness of

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breath, feeling light-headed, and fear of losing control (American Psychiatric Association, 2013). Obsessive–Compulsive Disorder Individuals with Obsessive–Compulsive Disorder (OCD) present with obsessions, compulsions, or both. Obsessions are intrusive and unwanted thoughts, urges, or images that are persistent and recurrent. Individuals may try to ignore the obsessions by suppression or through some other action, such as performing a compulsion. Compulsions are repetitive acts individuals engage in rigidly in response to an obsession or rule. The obsessions or compulsions cause clinically significant impairment or are time consuming, taking more than one hour per day (American Psychiatric Association, 2013). Hoarding Disorder Individuals with Hoarding Disorder have persistent difficulty parting with possessions, regardless of the actual value of the items. The difficulty parting with items is compounded by distress with discarding items. Such difficulty parting with possession results in cumulating possessions that congest and clutter active living spaces. Notably, the criteria may still be met if living areas are uncluttered due to family intervention (American Psychiatric Association, 2013). Other Related Disorders Also included within anxiety disorders are Separation Anxiety Disorder, Selective Mutism, Specific Phobia, Agoraphobia, Substance/MedicationInduced Anxiety Disorder, Anxiety Due to Another Medical Condition, Other Specified Anxiety Disorder, and Unspecified Anxiety Disorder. Other Specified Anxiety Disorder is diagnosed when symptoms of anxiety are causing clinically significant distress but do not fully meet criteria for any other anxiety-related disorder. The other specified diagnosis is used when the clinician wishes to specify why the client does not meet full criteria (American Psychiatric Association, 2013). Assessment Recommendations There are a number of general tools used to assess couples’ levels of distress and functioning to inform treatment recommendations. A  meta-analytic review of couples treatment modalities and levels of distress showed Emotionally Focused Therapy to be significantly more effective than Behavioral Marital Therapy for couples with moderate levels of distress (Wood, Crane, Schaalje, & Law, 2005). Tools such as the Marital Assessment Test (MAT)

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and Dyadic Adjustment Scale (DAS) can be used to assess distress levels. Other marital satisfaction measures include the Revised MAT (RMAT), Revised DAS (RDAS), and Kansas Marital Satisfaction Scale (KMSS). Accurate assessment at the onset of treatment is helpful not only in determining course of treatment and interventions but also in assessing progress. General assessment of distress and functioning is critical when determining treatment goals, interventions, and approaches. Along with general measures of couples’ level of functioning, there are a number of specific measures to assess for severity of specific disorders. The Beck Anxiety Inventory (BAI) is a self-report measure completed by the client to assess for symptoms of anxiety. The Social Phobia Inventory (SPIN) and Mini-SPIN self-report measures assess more specifically for symptoms of social anxiety disorder (Connor, Kobak, Churchill, Katzelnick, & Davidson, 2001). The Liebowitz Social Anxiety Scale (LSAS) is another brief self-report measure that can be useful in assessing for the presence and severity of social anxiety disorder. The APA has created a number of “emerging measures” available for use to help advance the research and clinical evaluation of certain disorders. One such measure is the Severity Measure for Panic Disorder–Adult (American Psychiatric Association, 2013). Finally, a number of assessment measures are available to help assess for the presence and severity of OCD symptoms. The Yale–Brown Obsessive– Compulsive Scale (Y-BOCS) has a number of variations to suit different settings and evaluations styles. The Y-BOCS self-report measure comprises a symptom checklist and severity scale to rate both obsessions and compulsions (Rapp, Bergman, Piancentini, & McGuire, 2016). In addition to a self-report measure, a clinician-rated measure, the Dimensional Yale–Brown Obsessive–Compulsive Scale (DY-BOCS), is also available. Shorter OCD assessment tools include the Obsessive–Compulsive Inventory–Revised (OCI-R), the Florida Obsessive–Compulsive Inventory (FOCI), and the Dimensional Obsessive–Compulsive Scale (DOCS). The described measures simply provide a “jumping off point” for consideration and can be particularly helpful when building and revising assessment practices. Other measures include the Anxiety Disorder Interview Schedule (ADIS), which has been shown to discriminate among anxiety disorders and is able to assess and differentiate for diagnosis of OCD (Rapp et al., 2016). These measures can be used within couple therapy to assess the severity and impact the anxiety disorder has on the individual and then the couple as a whole. Assessing for the couple’s attachment styles may also be useful, given certain styles’ correlation with anxiety disorders. A  number of self-report measures, including the Relationship Questionnaire (RQ) and the Experience in Close Relationships–Revised (ECR-R), can be given to the couple to assess their individual attachment styles. Structured interview tools, such as

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the Attachment Style Interview (ASI), can also be utilized by the clinician to help assess for attachment styles. Cultural Considerations and Suggestions for Culturally Competent Practice Research has consistently shown that minority populations tend to underutilize mental health treatment and have higher rates of early dropout (Griner & Smith, 2006). One factor that may contribute to the issue considers that “the cultural values of people of color may be incongruent with traditional mental health practices” (Griner & Smith, 2006). Clinicians may not overtly, intentionally, or consciously discriminate against cultural minorities; however, the clinician’s lack of awareness and knowledge about clients’ cultural backgrounds may contribute to problematic care of clients. Traditional treatment models and theories may not innately be inclusive and culturally sensitive. Therefore, it is the duty of the clinician to acknowledge multicultural issues and commit to culturally inclusive and sensitive practice. Additionally, Griner and Smith (2006) note that clients of color may be mistrustful of mental health services due to histories of oppression and racial disparities. Availability and access to therapists of clients’ own ethnic background may often be limited. Language is another important component of culture as the lack of available therapists who speak the client’s native language can also be a barrier to treatment. Griner and Smith noted, “interventions conducted in the clients’ native language (if other than English) were twice as effective as interventions conducted in English.” (p. 2) Additional barriers can include proximity issues (lack of mental health professionals in the community) and affordability of services. While DSM offerings, including the Cultural Formulation Interview, are a great start to cultural inclusion, more needs to be done. Clinicians can better understand clients’ beliefs and presentations by engaging in open, non-judgmental conversations about clients’ view of their presenting issues. Levels of acculturation and differences in communication styles should also be assessed as part of culturally competent practice. Being aware of cultural issues and barriers to treatment is the first step in developing multiculturally competent practice. Case Example: Rachel and Ryan Rachel and Ryan (both European American) have been in a committed relationship for ten years and have been married for seven years. They are in their early 30s, have a 3-year-old son, and are expecting another child. Rachel, a practicing speech pathologist, and Ryan, an active-duty army soldier, have lived on multiple military bases for the duration of their marriage. They have sought out treatment due to recent difficulties feeling connected,

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an increasing number of fights, and the stress stemming from Rachel’s difficult pregnancy. Rachel scheduled therapy sessions and reported that Ryan took some convincing to attend. Since early in the relationship, Rachel reported going through periods of time where Ryan “disconnects” and does not feel “present” even when they are sharing the same space. Rachel also reported “dealing with things” in a notably different manner. “I can’t keep things in or just walk away when there is a problem. I have to talk. Ryan just bottles things up until he can’t anymore.” Ryan appeared frustrated during this description and noted, “I  don’t need to over-analyze every aspect of our life. I  can let things rest.” The couple reported that the tension between them escalated around the time they decided they wanted to start a family. They attempted to conceive a child for two and a half years before starting fertility treatments. Rachel described this time as the “darkest and most defeating” time of her life. “I felt like a failure.” Ryan was quick to comfort Rachel as she became tearful, noting “I hated seeing her in so much pain.” They were fortunate to have quick success with their fertility treatments, and their son was born within a year and half of beginning treatment. Despite their joy for starting a new family, their pregnancy and first year with their child were complicated because Rachel struggled with postpartum anxiety six months after their son was born. She stated that “though I have always been a worrier I lived in absolute terror for the 1st six months of our son’s life.” While her anxious symptoms had intensified postpartum, Rachel described intense rumination, panic, difficulty concentrating and making decisions, and irritability since early in her pregnancy. Ryan noted, “I felt hopeless. Nothing I did or said would help.” After six months of “paralyzing panic attacks” and a general decline in functioning, Ryan insisted Rachel seek help. Therapy and a brief period of time on medication “pulled Rachel out of the haze.” “I felt like I could think again. I was me again.” While Ryan denied any changes or residual effects from Rachel’s experience with anxiety, Rachel believed that her anxiety made them emotionally distant from one another. Ryan spent more time at the gym and on timeconsuming projects at work. Rachel believed that Ryan volunteered for a lengthier deployment because he was unhappy at home. Ryan reported some truth to this and stated that he responded to Rachel’s anxiety with anger and frustration. Rachel’s anxiety symptoms worsened since learning about Ryan’s pending deployment. Her panic attacks and irritability returned. The couple also discovered they were newly pregnant, without going through IVF treatments. Both Rachel and Ryan were concerned about how she would manage a toddler, a newborn, and her career on her own. Additionally, this will be

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the longest Ryan will have been away. Ryan avoided eye contact throughout much of the session and admitted to dissatisfaction regarding having less time as a couple. “I love my son, but I miss my wife. Half the time we don’t even get to go to bed at the same time; and, by the time we get a moment, she is usually so anxious she can’t enjoy anything.” Rachel agreed with this sentiment and expressed guilt over her anxiety “getting in the way.” Assessment Ryan and Rachel participated in an attachment-sensitive clinical interview and completed an objective personality measure, along with self-report inventories and brief symptom inventories. Rachel Rachel, the oldest-born of three girls, was raised by both of her parents. Her father was in the army until she was 12 years old. Her mother, primarily a homemaker, returned to work when Rachel was 16 years old. She described her family as a “hard-working, blue-collared family.” Both of Rachel’s parents remain married and are an active part of her life. From an early age, Rachel learned certain expectations were held around emotions; unless positive, they should not be shown. Rachel, an expresser, often struggled with this family code. Fear and sadness were particularly unwelcome in her family home. “Those emotions meant weakness; and weakness wasn’t allowed.” Despite this avoidance of emotions, Rachel believed her mother struggled with anxiety as well. “When I was a kid, I really couldn’t figure out what was happening. My mom would become so angry during any difficult times. Times you would typically just be worried or afraid.” Rachel seemed to emphasize her mom’s “up and down” emotionality, noting “you never knew what to expect. One minute things were great, the next she was yelling and threatening to leave us. It always left me shaking and feeling sick.” Her father, while not as reactive, was typically unavailable. Ryan Ryan was also raised by both of his parents. His family, however, struggled significantly in terms of financial stability. This resulted in his parents working multiple jobs and often leaving their three children on their own or with various babysitters. Ryan is the middle-born child and self-described as the “black sheep” of the family. He described always feeling different from his family and often felt misunderstood, resulting in feeling he could not turn to his parents for support and care. Ryan also described years of bullying in school due to his reserved and thoughtful personality style; being small in stature as a child also made him an easy target. As Ryan grew older, he reported an increased withdrawal emotionally from others. “I couldn’t really relate to anyone. People didn’t think like me, at

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home or school.” Ryan’s gifted intellect meant he often struggled to relate to his peers. As Ryan progressed throughout school, he became less of a target for bullying, as he matured physically, but remained on the periphery. “I was lucky I met Rachel when I did. I think I would’ve led a very isolated life if I kept on that path.” DSM-5 Considerations After clinical interview and assessment, it was determined that Rachel met the diagnostic criteria for Generalized Anxiety Disorder (GAD) with panic attacks, though her pregnancy might be intensifying her GAD symptoms. Ryan’s presentation, possibly shaped by his attachment style and experiences in the military, seems influenced by being a partner of someone struggling with an anxiety-related disorder. It should be noted that Ryan does not have any PTSD symptoms. Case Conceptualization: Individual and Couple Individual Case Conceptualization Rachel’s general anxiety and worry began in childhood where she was able to recognize the struggles of others but was actively discouraged for broaching the topic, leaving her to feel “crazy” and “weak” for acknowledging and attempting to address issues. Rachel often worried about how her mother would respond to her, what she could do to avoid the negative appraisement of her mother, and how she could express herself and have her needs met. Rachel’s anxiety has become internalized, leading to rumination and expression of anxiety-related symptoms. Ryan grew up in a low socioeconomic status family as a middle child. He and his siblings were often left alone with no support from their parents. Ryan described feeling misunderstood and as an outcast in his family and with peers. As a very intelligent child, Ryan felt he could not relate to others and was often bullied due to his shyness and small stature. Thus, he became increasingly reliant on himself and led to his emotional attachment from others. As such, Ryan does not have much experience with expression or identification of emotions, or how to appropriately address issues with another person. He tends to shut down and detach when having to respond to emotions of another person. Couple Case Conceptualization Rachel and Ryan’s early childhood experiences within their family of origin and general attachment styles impact their social and relational functioning. Rachel’s early insecure attachment style has led to some attachmentrelated anxiety, leading her to worry whether Ryan is available, responsive, and attentive to her needs. Ryan’s early attachment style may be described as

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dismissive-avoidant. Ryan often had to parent himself and would seek isolation and avoidance from others due to feeling misunderstood and a lack of ability to relate to his family. As such, Ryan may appear to be more focused on himself and his needs. Their couple dynamics are shaped by Rachel coming from a childhood where her voice and expression were stunted and Ryan having to depend and rely on himself growing up. Rachel is apt to identify problems in their relationship, while Ryan may be unaware of or ignore them. This dynamic leads to problems within their relationship, with Rachel reaching out for support and validation and Ryan shutting down. Rachel may then default to feeling “crazy” and “weak” for bringing up issues or issues not being acknowledged, while Ryan may be struggling to react appropriately, possibly feeling bullied and misunderstood again when he does not know what to do but feels the expectation to respond. Ryan noted he “hates to see Rachel in pain,” but he may feel ill equipped in helping to address issues, leading him to feel hopeless and discouraged and further detach. Rachel then feels abandoned and alone with her needs not being met and internalizes feelings, leading to an outward expression of anxiety in a world she views as unresponsive, unpredictable, and chaotic at times. As the impact of early life attachment styles are explored with Ryan and Rachel, their couple dynamic and style become better conceptualized. Rachel may still continue to struggle to feel supported and validated, while Ryan may struggle to acknowledge issues and appropriately address them with another person. Using emotional-focused couple therapy to help the couple understand their attachment styles, how their dynamic influences their sense of anxiety and feeling safe with one another, and creating a safe environment where there can be an emotionally corrective experience will be critical in helping this couple better understand one another and work through their issues together. Cultural considerations such as their family of origin’s respective SES (Ryan lower SES and Rachel middle SES) and gender role expectations should also be explored in working with this couple. Treatment Considerations Both individual and couple therapy were recommended for Rachel and Ryan. Several types of couple treatment were considered, including cognitive–behavioral couple therapy; however, for both Rachel and Ryan, integrative behavioral approaches coupled with emotion-focused therapy were determined to be a better fit for this couple and were therefore utilized in treatment. During couple therapy, Rachel and Ryan were encouraged to openly explore their attachment styles, their needs, and how they attempt to have their needs met within their relationship. The findings from the attachment-sensitive interview were explored with Ryan and Rachel for both to better understand themselves, each other, and how their way of viewing the

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world and relationships was shaped. Building each other’s understanding of the other helped both to be more sensitive and understanding of the ways in which they both responded to one another. Ryan began to better understand that Rachel’s anxious behaviors and symptoms were often the result of her increased feelings of isolation from him and her overall distress in managing her many changing roles as a wife, mother, and provider. Rachel began to better understand Ryan’s responses to her not as indicative of intentional avoidance and detachment, but rather as him feeling overwhelmed with wanting to help but feeling at a loss as to how. As Ryan began developing his emotional vocabulary and understanding what underlies his emotions, he was better able to express himself to Rachel. By doing so, Rachel began to feel more supported and validated as both acknowledged issues. Rachel no longer felt “weak, crazy,” or alone in problems but felt she had a partner who could acknowledge issues to begin to work on effective problem solving. To assess treatment progress, the couple’s view of themselves, the other, and their emotional regulation was monitored throughout the counseling process. As treatment progressed, both Ryan and Rachel’s appraisal of one another and each other grew more favorable. They described their relationship as stronger, leading them both to feel better equipped to manage stressors. They were encouraged to routinely, and sincerely, compliment one another on their strengths and express gratitude for each other. Conclusion While the case illustrated in this chapter focused primarily on generalized anxiety, a number of anxiety related disorders are outlined in this chapter. Early attachment styles often impact couple relationships and even influence couple selection; thus, it is important to explore each individual’s attachment style in order to better understand relationship dynamics, identify issues, and form interventions to help each client have their needs appropriately met. Treatment of couples where an anxiety disorder is complex and several treatments, including EFT, CBCT, and integrative behavioral approaches, have been found to be successful in anxiety reduction, symptom management, and increased understanding for the couple of the impact of anxiety on their relationship and relational dynamics. From cultural considerations, to individual and family dynamics, each couple is unique in their expression of health and distress. Treatment should be adapted and individualized for each couple that comes for counseling. References American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing. Anxiety and Depression Association of America. (2016). Managing anxiety. Retrieved from https://adaa.org/living-with-anxiety/managing-anxiety

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Bateson, M., Brilot, B., & Nettle, D. (2011). Anxiety: An evolutionary approach. The Canadian Journal of Psychiatry, 56, 707–715. Brumariu, L. E., Obsuth, I.,  & Lyons-Ruth, K. (2013). Quality of attachment relationships and peer relationship dysfunction among late adolescents with and without anxiety disorders. Journal of Anxiety Disorders, 27, 116–124. doi:10.1016/ janxdis.2012.09.002 Connor, K. M., Kobak, K. A., Churchill, L. E., Katzelnick, D., & Davidson, J. R. (2001). Mini‐SPIN: A brief screening assessment for generalized social anxiety disorder. Depression and Anxiety, 14(2), 137–140. Cusimano, A. M., & Riggs, S. A. (2013). Perceptions of interparental conflict, romantic attachment, and psychological distress in college students. Couple and Family Psychology: Research and Practice, 2(1), 45. doi:10.1037/a0031657 Doron, G., Moulding, R., Nedeljkovic, M., Kyrios, M., Mikulicer, M., & Sar-El, D. (2011). Adult attachment insecurities are associated with obsessive compulsive disorder. Psychology and Psychotherapy: Theory, Research and Practice, 163–178. doi:10.1111/j.2044-8341.2011.02028.x Eng, W., Heimberg, R. G., Hart, T. A., Schneier, F. R.,  & Liebowitz, M. R. (2001). Attachment in individuals with social anxiety disorder: The relationship among adult attachment styles, social anxiety, and depression. American Psychological Association, Inc., 1, 365–380. doi:10.1037//1528-3542.1.4.365 Griner, D.,  & Smith, T. B. (2006). Culturally adapted mental health intervention: A  meta-analytic review. Psychotherapy: Theory, Research, Practice, Training, 43, 531–548. doi:http://dx.doi.org/10.1037/0033-3204.43.4.531 Klemetti, R., Raitanen, J., Sihvo, J., Saarno, S., & Koponen, P. (2010). Infertility, mental disorders and well-being—a nationwide survey. Acta Obstetricia et Gynecologica, 89, 677–682. doi:10.3109/00016341003623746 Mansfield, A. J., Kaufman, J. S., Marshall, S. W., Gaynes, B. N., Morrissey, J. P., & Engel, C. C. (2010). Deployment and the use of mental health services among U.S. Army wives. The New England Journal of Medicine, 362, 101–109. Marganska, A., Gallagher, M., & Miranda, R. (2013). Adult attachment, emotion dysregulation, and symptoms of depression and generalized anxiety disorder. American Journal of Orthopsychiatry, 83, 131–141. doi:10.111/ajop.12001 Pietromonaco, P. R., DeBuse, C. J., & Powers, S. I. (2013). Does attachment get under the skin? Adult romantic attachment and cortisol responses to stress. Current Directions in Psychological Sciences, 22, 63–68. doi:10.1177/0963721412463229 Rapp, A. M., Bergman, R. L., Piancentini, J.,  & McGuire, J. F. (2016). Evidencedbased assessment of obsessive–compulsive disorder. Journal of Central Nervous System Disease, 8, 13–29. doi:10.4137/JCNSD.S38359 Schimmenti, A., & Bifulco, A. (2013). Linking lack of care in childhood to anxiety disorders in emerging adulthood: The role of attachment styles. Child and Adolescent Mental Health, 20, 41–48. doi:10.1111/camh.12051 Wood, N. D., Crane, D. R., Schaalje, G. B.,  & Law, D. D. (2005). What works for whom: A  meta-analytic review of marital and couples therapy in reference to marital distress. The American Journal of Family Therapy, 33, 273–287. Zaider, T. I., Heimberg, R. G., & Iida, M. (2010). Anxiety disorders and intimate relationships: A study of daily processes in couples. Journal of Abnormal Psychology, 119, 167–173. doi:10.1037/a0018473

7 THE TRAUMATIZED COUPLE Emily Petkus

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ouples who have experienced trauma may have conflicts that are quite painful and make coping difficult. When one partner has experienced a trauma that caused them to view the world as a dangerous place, they have a profound loss of safety and trust. In addition to that change, their instinctual self-preservation strategies serve to isolate them further and confound the most painful and lonely symptoms of Post-Traumatic Stress Disorder (PTSD). Not only do individuals with PTSD need to learn (or relearn) how to hope and to connect to others, their loved ones need to learn how to help maintain stability and understand their traumatized partner’s emotional and safety needs. No matter the cause or consequence of trauma, the healing process between couples requires trust, safety, and connection from each partner. The couple that is the focus of this chapter struggles with symptoms of PTSD. The process of couple therapy must address the essential areas of trauma treatment and couple dynamics in order to work toward healing and resolution. This chapter begins with an overview of trauma symptoms, the impact trauma symptoms have on individuals and couples, and the dynamics between partners when a trauma disorder is present. A review of the DSM-5 characterizations of trauma disorders will follow in addition to a case conceptualization of the couple. Assessment, treatment, and cultural considerations will be addressed. A concluding note will summarize the recommendations for working with this couple. Overview: Trauma Symptoms Traumatic events challenge people’s assumptions about the world and their purpose and place in it. Trauma survivors have difficulty feeling completely

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secure, thus challenging the pre-trauma belief that the world is a safe place. When core beliefs are challenged, individuals often experience intrusive and uncontrollable thoughts about the event. PTSD symptoms impair a trauma survivor’s ability to effectively relate to others. In couples, this results in the non-PTSD partner feeling less satisfied with the relationship. Symptoms of PTSD can cause difficulty with communication and prevent secure attachment and the development of intimacy, which results in loss of safety in a relationship. One example is the PTSD symptom of avoidance. Efforts to avoid stimuli associated with a traumatic event include distressing emotions, memories, or thoughts (American Psychiatric Association, 2013). Symptoms also include an effort to avoid external reminders like activities, people, and places (American Psychiatric Association, 2013). This avoidance interferes with intimacy between partners, while other symptoms like anger and agitation reduce the sense of safety within a relationship (Lambert, Engh, Hasbun, & Holzer, 2012). Intimacy and safety are critical components of satisfying relationships. Therefore, it is important for therapists to have an understanding of the complexities that trauma creates in individuals and in couples. The Impact of Trauma Symptoms PTSD symptoms are influenced by several factors. The type of trauma and gender of the trauma survivor can impact the non-PTSD partner. The length of time and severity of PTSD symptoms also influence the PTSD partner’s symptoms on their non-PTSD partner’s psychological and relationship distress (Lambert et al., 2012). Additional discussion on the impact of trauma symptoms in relationships will be discussed in more detail later in this section. Types of Trauma Combat Trauma A meta-analysis quantifying the associations between PTSD and intimate relationship problems found differences between military and civilian samples and the impact of PTSD on intimate relationships (Taft, Watkins, Stafford, Street, & Monson, 2011). Stressors specific to the military, such as exposure to life-threatening situations over prolonged periods of time, lead to deficits in the processing of social information and anger (Taft et  al., 2011). Combat-related PTSD may be more likely to be associated with anger and hostility than PTSD not related to combat (Lambert et al., 2012). These two symptoms are most commonly associated with higher levels of intimate relationship aggression (Taft et al., 2011). The role of PTSD in aggression is highlighted by physiological reactivity, anger, social problem-solving deficits, and other psychiatric problems. Each of these symptoms is also correlated

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with the negative effects of substance use in partner dissatisfaction in PTSD couples (Taft et al., 2011). Among the relevant differences that can be identified in PTSD, men and women can experience differences in the expression of symptoms and attunement to their partner’s emotional experience (Lambert et al., 2012). A person not experiencing PTSD living with their partner who has PTSD increases the likelihood of experiencing stress, anxiety, and depression. Partners of people with PTSD can experience many stressors that result from caring for and living with a trauma survivor (Lambert et al., 2012). For example, there may be an increased strain on finances, responding to and managing trauma symptoms, and taking on additional responsibility to help their partner if they are unable to function in former roles. Learning about a spouse’s trauma could also result in the non-PTSD spouse developing symptoms and trauma responses like those exhibited by their partner (i.e., secondary traumatic stress) (Lambert et al., 2012). Childhood and Interpersonal Trauma Childhood abuse is a common cause of PTSD in children and adults. Even though childhood abuse is frequently underreported, the prevalence of childhood sexual abuse in the United States ranges from 6% to 36% and other forms of abuse range from 16% to 40% in the general population (Miano, Weber, Roepke, & Dziobek, 2017). According to childhelp.org, an organization that provides education, advocacy, and intervention services for children experiencing abuse, there are various forms of childhood abuse. Childhood physical, sexual, and emotional abuse and neglect can all lead to PTSD in childhood and adulthood (Childhelp, n.d.). Childhood maltreatment of any kind negatively affects the quality and stability of close adult interpersonal relationships. Children who experience maltreatment or abuse have difficulty developing healthy attachments, which is associated with insecure attachments in childhood and adulthood (Miano et al., 2017). Insecure attachments can lead to relationship impairments and distressed or unstable relationships in adulthood. The experience of trauma, however, intensifies a trauma survivor’s need for protective and secure attachments. Trauma also destroys the building blocks of healthy attachment emotions like trust and security. Trauma inflicted by one person onto another is a “violation of human connection” and renders the very nature of connection to others problematic (Johnson & Williams-Keeler, 1998). Wellfunctioning interpersonal relationships are important sources of health and quality of life. They also establish a protective factor against the development of adult psychopathology that typically results from childhood maltreatment (Miano et al., 2017). Interpersonal dysfunction can be caused by changes in social cognition or the ability to understand what people intend, think, and feel. Some researchers propose that adverse family environments lead to changes in

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emotion processing and social competence (Miano et al., 2017). Romantic relationships require a general understanding of thoughts and feelings and were found to be important for relationship quality, forgiveness, and conflict management (Miano et al., 2017). The Process and Dynamics Between Partners With Trauma Disorders Partners interact with each other in many complex ways (Alexander, 2014). As mentioned earlier, relational functioning deteriorates after traumatic events. This deterioration can include increased withdrawal from partners, reduced relationship satisfaction, and increased divorce rates. In contrast, some evidence suggests an improvement in relationships following traumatic events like natural disasters. The improved relationship following this type of trauma resulted in an increased number of marriages and birthrates and greater feelings of closeness toward loved ones (Canevello, Michels, & Hilaire, 2016). In these cases, the mutually experienced trauma sets the stage for both significant distress and positive change or growth (Canevello et al., 2016). This differs from other types of trauma because a couple can bond around their shared experience as they heal together. In couples where one person experiences a trauma, however, the trauma partner may be isolated from their non-trauma partner because it is not a shared experience. Couples can also influence each other through mutual growth. In addition to post-traumatic growth and relationship functioning, specific symptoms have been identified as contributing to psychological distress in relationships. The symptoms that PTSD partners experience have a significant influence on their non-PTSD partner. Psychological distress in couples with PTSD has been measured by assessing relationship quality. The results of these measurements indicated gender differences between males and females in couples where one partner has PTSD and the other does not. Increased levels of psychological distress were shown when the partner with PTSD symptoms was male and the spouse was female. These results might be explained by the differences in emotional attunement to partners and differences in the expression of symptoms among other gender roles that are typically seen in heterosexual couples (Lambert et al., 2012). Gender differences in couples with PTSD can also be observed in the expression of PTSD symptoms. For example, women may be more likely than men to experience and express internalizing symptoms resulting from trauma relative to externalizing problems that men typically experience (Taft et al., 2011). In other words, externalizing symptoms of PTSD may include negative changes in thoughts and mood that result in the perpetration of interpersonal aggression, and internalizing symptoms may include the isolation and self-blame that result from avoidance of stimuli associated with the traumatic event (American Psychiatric Association, 2013). PTSD remains a significant predictor of

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marital dissatisfaction. In heterosexual couples where women have PTSD, their experience of PTSD symptomatology is less likely to manifest itself in the form of relationship aggression, but may have particularly damaging impact on overall relationship satisfaction (Taft et al., 2011). Neglected children might have learned to compensate for the lack of interaction with cognitive closeness. Emotional attunement between children and parents might not be possible with emotionally or physically unavailable parents (Miano et al., 2017). The resulting childhood neglect might be associated with a hyperactivating interpersonal stress coping strategy in adulthood that overrides possible negative outcomes of cognitive closeness in relationship-threatening situations (Miano et al., 2017). In other words, the trauma that results from childhood neglect specifically affects the development of healthy emotion regulation, persistent negative beliefs and emotions, and difficulty developing closeness to others. Relational Conflicts in Trauma Couples Partners in distressed relationships with one partner who has experienced a trauma struggle with overwhelming negative affects like anger, sadness, shame, and fear, while also experiencing helplessness and hopelessness. The focus on personal safety and self-protection rather than connecting to others can be paralyzing. They become stuck in cycles that constrict and reinforce maladaptive attachment patterns. The Trauma Couple in Therapy When a couple seeks therapy for PTSD, both partners are likely experiencing distress and dissatisfaction in the relationship. Both partners have likely developed maladaptive coping strategies resulting from one or more of the symptom categories of: intrusive re-experiencing, avoidance, negative alterations in cognition, and hyperarousal or hypervigilance (American Psychiatric Association, 2013). Several therapy goals and needs must be considered for the trauma couple. An important goal for the treatment process is restoring hope between the couple. Three major processes help foster hope in couple therapy: developing a strong therapeutic relationship, ending negative interactions within the couple, and successfully navigating challenging issues (Oseland, Schwerdtfeger Gallus, & Nelson Goff, 2016). The quality of support PTSD couples receive can alter the effects of trauma on long-term functioning. Positive social support includes behaviors like active listening, expressing concern, helping with problem-solving, or just providing support for someone who is coping with a problem. Positive social support received from others in response to a trauma disclosure helps to alleviate distress by enhancing cognitive processing (Evans, Steel, Watkins, & DiLillo, 2014) and allows trauma survivors to develop a more adaptive narrative of trauma. Invalidation,

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on the other hand, can exacerbate trauma symptoms, lead to avoidance of trauma processing, and strengthen maladaptive cognitive distortions about the trauma (Evans et al., 2014). Exposure to trauma shapes the view of oneself and of relationship expectations. This change results in adult survivors of trauma perceiving threats to personal safety within their relationship. A globally supportive relationship safeguards partners from distress, boosts self-esteem, and enables the ability to cognitively reevaluate stressors as less threatening (Evans et  al., 2014). Understanding the role of positive social support, developing skills to provide positive support to one another, and restoring hope between partners are important components of couple therapy for PTSD couples. DSM-5 and the Trauma Couple The trauma recovery process includes establishing safety for the survivor, reconstructing the traumatic story, and restoring the connection between the trauma survivor and community (Oseland et al., 2016). The most critical and foundational component of effective treatment of trauma is establishing safety and stability. In couple therapy, this need requires the additional emphasis on the therapeutic relationship and process as safe and stable for both the survivor and partner. Trauma survivors struggle to regulate emotion, which can lead to increased levels of relational conflict (Oseland et al., 2016). Additional issues leading to relationship conflict include reduced capacity for adaptability, role disruption, boundary shifts, and changes in the relationship dynamic. For these reasons, safety and stability within the therapeutic relationship prior to addressing the trauma is essential (Oseland et al., 2016). Gaining control over maladaptive behaviors like self-harm, suicidality, substance use, and relational aggression is another important component to the therapeutic process. Survivors must feel a sense of control in making decisions during the treatment process in order to take ownership of the recovery process. A failure to establish safety, security, stability, and control may result in re-traumatization or an exacerbation of trauma symptoms (Oseland et al., 2016). Establishing safety and stability demands a level of ongoing crisis management in the therapeutic process, depending on how recently the trauma occurred and the severity of the PTSD. This process should not be rushed. Avoiding intrusive re-experiencing of the trauma is often unsuccessful for survivors. Building a narrative is important for teaching survivors how to recognize and manage unwanted memories, while reducing secrecy, reactions to triggers, and extreme behavioral and interpersonal patterns is another goal for trauma treatment (Oseland et al., 2016). The basis for trauma-focused couple therapy involves working through trauma by creating a shared couple’s narrative, processing symptoms, and learning to self-regulate so that the trauma-related individual and systemic

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symptoms can become more manageable (Oseland et  al., 2016). Trauma survivors often disconnect from their partners in an effort to avoid symptoms. This results in unsatisfactory and incomplete communication between partners. It is important to consider that avoidance behaviors stem from an inability to self-regulate, which leads to higher levels of emotional reactivity in trauma couples (Oseland et  al., 2016). Therefore, survivors should be encouraged to identify a means of self-expression to share their trauma experience “testimony” with their partner (Oseland et  al., 2016). Telling a painful story in the safety of a protected relationship and safe environment can produce change in the processing of a traumatic memory (Oseland et al., 2016). The goal here is for the survivor to be able to share the story and monitor their anxiety and other intrusive symptoms instead of avoiding or isolating (Oseland et  al., 2016). Once the narrative has been shared, both partners experience a sense of grief and loss. They are then encouraged to release these intense feelings of anger and helplessness together in order to reconstruct the memory and continue to self-regulate and develop deeper connections to their partners (Oseland et al., 2016). A final component to the trauma recovery process for couples is establishing connections to extended family members and community, which helps foster health and resilience among trauma survivors (Oseland et al., 2016). Disconnection between partners increases problems between couples in their sexual intimacy (Oseland et  al., 2016). Developing understanding and support for the trauma survivor is essential in the recovery process. When the trauma no longer dominates the survivor’s life, it ceases to be a barrier to intimacy, which allows survivors and partners to develop healthy interpersonal relationships (Oseland et al., 2016). Improved intimacy leads to increased connection between partners and new patterns of interaction. Through the therapy process, examination of closeness, support, relationship resources, coping mechanisms, intimacy, and relationship dynamics help couples redefine their relationship and develop healthy patterns of interaction (Oseland et al., 2016). DSM-5 and Trauma Disorder Trauma is characterized as a direct experiencing, witnessing, or learning of an instance that involves the actual or threatened death, serious injury, or sexual violence to oneself or to others (American Psychiatric Association, 2013). Traumatization can occur when one’s perceived internal and external resources are incapable of helping them cope with an overwhelming or frightening experience (Oseland et al., 2016). This can include single incidents or a series of prolonged experiences that cause psychological and/or emotional distress that undermine the trauma survivor’s perceived sense of control, connection, and meaning. Trauma and stress-related disorders are based on the notion that many of the symptoms experienced by survivors are

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anhedonic and dysphoric in nature. In other words, symptoms are bothersome to the survivor and represent a loss of interest or change from previous functioning (Oseland et al., 2016). The diagnostic criteria for Post-Traumatic Stress Disorder (PTSD) consist of four symptom categories: intrusive reexperiencing, avoidance, negative alterations in cognition, and hyperarousal or hypervigilance (American Psychiatric Association, 2013). Hypervigilance presents as an individual’s persistent expectation of danger in the environment, causing survivors to be “stuck” in their previous traumatic experiences. This symptom can be further impacted by difficulty sleeping, irritable mood, trouble concentrating, and an exaggerated startle response (American Psychiatric Association, 2013; Oseland et al., 2016). Trauma survivors often engage in self-preservation behaviors such as avoiding experiences that may trigger intrusive symptoms, which can be conscious or unconscious. This causes feelings of detachment and a restricted range of affect for the trauma survivor. Numbing may also lead survivors to utilize maladaptive coping strategies to manage their emotional distress, such as problematic substance use, risk-taking behaviors, and deliberate social isolation from others. As mentioned earlier, there is a loss of interest in previously enjoyed activities and often exaggerated negative beliefs about one’s self and the environment, leaving the individual in a perpetually negative emotional state (Oseland et al., 2016). Clearly these patterns of behaviors can significantly damage couples’ relationships, especially if one’s non-PTSD partner is uneducated on how trauma symptoms manifest. Assessment Considerations Another important process for trauma couples in therapy includes the adequate assessment of individual and relationship dynamics. This includes assessing severity of symptoms, individual personality styles, functional and maladaptive relational dynamics, safety within the relationship, and relationship satisfaction and expectations. Trauma couples in therapy are encouraged to establish safety in relationship by building healthy communication skills that enhance social support between partners. Training in active listening skills will help couples better validate one another’s feelings and experiences while avoiding potentially harmful criticism or blame (Evans et al., 2014). Many treatment approaches for trauma survivors are designed to help survivors understand trauma and its effects. Therapists help survivors identify thoughts that elicit feelings of anxiety, distress, and coping strategies to replace maladaptive cognitions and coping. Other treatment approaches emphasize the interpersonal nature of trauma and its effects and work to improve interpersonal relationships as a way to heal from trauma (Oseland et  al., 2016). Traditional and recovery-focused therapy approaches at the individual level alone may be inadequate. Support from others in the treatment process can enhance a survivor’s potential to reach meaningful

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improvement. The primary trauma survivor’s process of hyperarousal, intrusive re-experiencing, negative alterations in cognition, and avoidance can negatively affect their partner. These factors influence the symptom exchange between the primary survivor and the partner, who develops secondary trauma symptoms that intensify interpersonal conflict and the disruptions between the partners (Oseland et al., 2016). Case Conceptualizations: Individual and Couple A case conceptualization will help illustrate the complex nature of PTSD in couple therapy. In this conceptualization, a summary of presenting concerns will be offered from the perspective of an individual and from a couple in therapy. After exploring the dynamics presented in both conceptualizations, a plan for treatment for the couple can be developed and implemented. Case Conceptualization A comprehensive conceptualization of an individual’s personality dynamics, developmental issues, and social and health history facilitates the creation of an appropriate treatment plan that is tailored for the individual client. Gaining a thorough understanding of an individual’s cultural background, family-of-origin dynamics, and other relational patterns helps therapists develop understanding of their clients’ needs in therapy. Through the process of developing a case conceptualization, therapists work to identify their client’s core issues, including maladaptive patterns in relationships, coping styles, and personality dynamics. For individuals coping with PTSD, this pattern consists of beliefs such as “the world is unsafe, I cannot trust anyone, it is my fault that I was hurt, therefore I must isolate and protect myself from everything.” For couples, the case conceptualization functions as a way to understand and explain difficulties, distress, and concerns reported by the couple. A  comprehensive conceptualization of the relationship dynamics includes a thorough assessment of systemic patterns. These include each member of the couple’s family-of-origin dynamics; the dynamics between the couple, such as strengths and resources, communication, and attachment styles; distribution of power; and intimacy. The couple case conceptualization should include their individual dynamics for each partner as well. For example, some conflicts could be explained by the PTSD partner’s anger, avoidance, and numbing behaviors, leading to the non-PTSD partner to have increased levels of distress, decreased healthy communication, and lack of intimacy. The couple conceptualization should inform the treatment plan and interventions as well as address both the couple and individual systemic dynamics. An important component to the couple case conceptualization is a thorough understanding of the cultural dynamics that exist for the couple.

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Couples who are struggling with PTSD have worldviews that have been shaped by the trauma. The worldview of the trauma partner is that life hurts; the world is scary, unsafe, and uncontrollable. They avoid as many reminders of the traumatic event as possible, which leads them to isolate from even from positive, healing connections to people and places. Even though the trauma partner desperately needs safety and connection with others, trust in and attachment to other people is dangerous (particularly when they have survived an interpersonal trauma). Their self-view and mood are resolutely negative, and they have an inability to experience positive emotions. When their non-PTSD partner provides love and support, they believe they do not deserve it or do not understand why their partner is loving and supporting them. This repeated dynamic continues to isolate the trauma partner from receiving or feeling the love, support, and connection they need to heal and causes the non-PTSD partner to shut down the failed attempts at intimacy. They continuously distort the cause and consequence of the trauma as their own fault, and they might behave recklessly or repeat self-destructive behaviors as a result. The non-trauma partner’s worldview is one of desperation and defeat. Despite their best efforts to support and love their partner with PTSD, they seem to fail. After many attempts to understand and accommodate their partner’s needs, they lose hope because nothing seems to work. The feelings of defeat lead to disconnection from their partner and loneliness. It can even lead to feelings of resentment. When their partner isolates, struggles with negative mood and self-blame, and experiences triggers that lead to intrusive re-experiencing of the traumatic event, the non-PTSD partner feels like a perpetrator of the trauma, which leads to distancing and disconnection. Cultural Considerations The influence culture has on an individual’s experience in the world is significant. It also influences the experience of therapy. It is an instrumental part of the therapy process to continually consider a client’s or couple’s cultural background. The following dimensions of culture should be considered when working with any client or couple: race, gender identity and expression, religious affiliation, social class, age, and sexual orientation. When two people begin a relationship with one another, the influence of their life experiences plays a role in the relationship dynamic. A cultural formulation is part of a thorough case conceptualization and explains how cultural dynamics have influenced issues in a couple’s life. Each partner’s cultural identity shapes their personality, functioning, and perception of the problems within the relationship. Each partner’s cultural identity and level of acculturation provides an explanation for the development of interpersonal issues, relationship functioning, and strategies for problemsolving. The significance of determining personality and cultural dynamics

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for each partner in a couple is an important process for determining how to incorporate a culturally sensitive treatment plan. Treatment Considerations The treatment of PTSD often includes individual therapy as well as couple therapy. Research indicates that individual therapy alone may not be sufficient for people who have experienced a traumatic event and experience PTSD. An emotionally focused treatment approach (EFT) to treating couples with PTSD has been well-supported and empirically validated in research. Emotionally focused couple therapy helps partners reprocess emotional responses to each other and change the way they interact with one another to create a more secure attachment (Johnson  & Williams-Keeler, 1998). With this approach, a relationship of connection and caring is established in therapy that fosters new learning in many areas. This process creates a corrective emotional experience for the PTSD partner. Once emotional engagement with the non-PTSD partner becomes safe, the PTSD partner is able to be engaged in the process, more open to positive healing experiences, and less immersed in their trauma (Johnson & Williams-Keeler, 1998). Couple therapy can help redefine the relationship within a context of worthiness of acceptance and support from a caring partner. The safety of the therapeutic relationship also allows for reprocessing of traumatic experiences between couples, which builds a powerful bond between partners. This bond, then, becomes a protective factor against re-traumatization or further traumatic impact on the relationship (Johnson & Williams-Keeler, 1998). Emotionally focused couple therapy for PTSD involves many phases. The focus of this approach is reprocessing the emotional responses that organize attachment behaviors. The most important features of this approach include these three stages: (1) stabilization; (2) building self and relationship capacities; and (3) integration (Johnson & Williams-Keeler, 1998). Within each of the three stages, the following treatment goals guide the therapist: (1) creating and maintaining a safe therapeutic alliance; (2) restoring hope and healthy relationship dynamics; and (3) integrating new interactional patterns within the relationship (Johnson & Williams-Keeler, 1998). What follows is a brief description of the steps that guide goals within treatment phases. Stabilization The beginning stages of EFT facilitates the process of stabilization for the couple. Creating and maintaining a strong and safe alliance with the therapist is essential to this process. The first part of this step is an initial assessment. The therapist conducts thorough clinical interviews with each partner separately and a conjoint clinical interview with the couple together. Next, the

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relationship cycles and patterns are identified. Following the first two steps is the process of identifying and understanding the underlying feelings for each partner. The final step in the stabilization process for EFT couple therapy for PTSD is the process of framing the problem through the identification of the negative patterns of interaction in the couple. In other words, couples work to redefine the problem. The PTSD partner is not the problem; PTSD is not the problem. Instead, the negative patterns of interaction between the couple are the problem. During this first step, partners begin to learn how each of them is suffering from the trauma. They begin to develop empathy for themselves and for each other as they begin to understand one another’s attempts to cope with the pain the trauma caused. An example of a successful outcome of this stage of therapy would be the understanding that each partner’s attempts at coping with pain can sabotage healthy emotional connection between them. Building Self and Relationship Capacities The next few steps of EFT for couples with PTSD help partners cope with the trauma in new ways. Working through this process together helps couples nurture the bond between them, which facilitates the development of contact and trust. The first of three primary steps in the process of building self and relationship capacities is owning the longings and fears that arise in relationships. This is a vulnerable process for both partners. The PTSD partner is faced with re-experiencing painful emotional states that they previously had difficulty managing on their own. The non-PTSD partner is faced with acknowledging their own relationship needs while their partner begins to connect with them about their individual relationship needs as well. The next step in this phase is accepting each partner’s longings and fears. This process requires exploration of emotional experiences within the relationship. As re-experiencing symptoms arise and are clarified, partners describe their interactions and experiences of their partner while the therapist reflects and validates both partners’ emotional experiences. The final step in this phase is for each partner to ask for their needs to be met in a way that evokes empathic responsiveness from their partner. The steps in this phase of EFT for couples necessitates partners establishing and relying on the safety of the therapeutic alliance and the renewed sense of safety within the relationship. The effects that are identified in this stage are explored and amplified; negative affects are contained to help partners remain engaged and connected with each other’s experiences during the process. The therapist’s ability to accept, name, and crystallize each partner’s experience as they experience it allows for the development or ­improvement of affect tolerance, regulation, and integration. The new experiences that cou­­ ples have with EFT results in less of a need for trauma survivors to cope through detachment, emotional numbing, and avoidance of intimate contact

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with their partner. The new interactional cycles and patterns that emerge include improved empathic responses, which create space for partners to continue processing and reorganizing their traumatic experience within the safety of their relationship. Throughout this process, hope is slowly restored between the couple, and healthy relationship dynamics can begin to develop. Integration In the remaining steps, newly processed emotional experiences and a renewed sense of self are affirmed, specified, and integrated into the trauma survivor’s self-view. In other words, the PTSD partner’s narrative and selfview are rewritten. New ways of interacting are also integrated between partners. The first step in this phase involves identifying and integrating positive ways of coping with trauma-related relationship problems. The next step in this phase is integrating new interactional positions into the definition of the relationship. This successful completion of this stage of EFT is critical to the maintenance of gains made in therapy. Couples are able to find collaborative solutions to ongoing trauma issues, and the relationship is no longer organized around the trauma. The restoration or development of a secure and intimate relationship with a partner helps trauma survivors in many ways. Most significant is the development of a positive attachment, which restores selfefficacy, hope, and stability. Case Example: Rachel and John Rachel and John have been married for 15 years. This is their first time seeking couple therapy. Rachel is a graduate student and helps John run his business; she is 45 years old and is a first generation Filipino American. Rachel grew up in a family that believed issues should never be discussed outside of the family; issues that occur within the family are private matters. She was previously married and her husband died tragically in a car accident. Rachel described experiencing recurrent, distressing dreams and chronic anxiety. She does not take any psychotropic medications and denies having any medical conditions. John is in his late 40s and of European descent. He and Rachel have 13-year-old twin boys. John has a bachelor’s degree in finance and is a wealthy investment banker. He reported building his business from the ground up and attributes his success to luck and persistence. John reported working long hours most days, stating that 70-hour work weeks were not uncommon for him. He claimed that working hard is part of his identity and duty. John reported experiencing chronic headaches. While meeting individually with their couple therapist, Rachel reported feeling pressure at work, school, and home. Rachel stated that the loss of her first husband was devastating. She reported witnessing her first husband be hit by a passing vehicle after they experienced a tire blowout on the interstate.

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It was very difficult for her to deal with the traumatic death of her husband. She reported still mourning his loss and experiencing vivid memories of him pinned to the concrete barrier on the interstate. Rachel also reported being unable to drive on the same interstate where he was killed. Rachel also disclosed that John becomes easily frustrated with her. She described feeling intense emotions, stating,

I

just can’t handle things sometimes. I feel things so intensely and I know my reactions are hard for John. He is a good dad to the boys and a good and loving husband. But I feel like he does not understand how terrible these nightmares are and how awful the loss of my first husband was.

John had difficulty understanding the purpose of coming to therapy with Rachel and was reticent to disclose anything about himself. During his clinical interview, he claimed that “he just didn’t know how anything could help.” John presented as guarded and spoke hesitantly in session. He often shifted his position while seated, appearing uncomfortable or restless. John monitored time regularly throughout the session, often glancing at his watch. John reported his biggest struggle was helping Rachel when she has “her tough times.” He reported that Rachel’s intense emotions are too much for him and admitted to backing off from her during those times. John appeared defeated and helpless when speaking about Rachel. Couple Case Conceptualization In their first couples session, John presented as withdrawn and Rachel presented as emotionally distraught. She was crying and reported becoming easily upset most days. Rachel reported feeling upset that John cannot understand her experiences. She reported that this has led to arguments between them, resulting in Rachel withdrawing and isolating from John. While Rachel described the problem, John looked absently at the floor. Rachel continued by describing how her nightmares and flashbacks have been affecting her at home, work, and school. When asked about the perception of the issues between them, John reported feeling completely helpless. He reported that he tries to understand but he just feels like a failure because he cannot help his wife. He explained that this frustrates him and leads him to argue with Rachel, and he knows that is not helpful. Assessment Considerations The assessment included comprehensive clinical interviews with John and Rachel individually and then a conjoint session to identify relational dynamics. The Clinician Administered PTSD Scale for DSM-5 (CAPS-5) was completed for Rachel and John.

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Cultural Consideration The cultural considerations for Rachel and John include gender, cultural identity, and dynamics. Rachel’s level of acculturation should be considered from other members of her family-of-origin, which shapes her worldview and her self-perception. While John’s cultural identity and dynamics do not appear to influence his perception of gender roles, his values and perceptions have been influenced by the men and women in his life. John’s perception of masculinity as “head of household” and his duty to provide and work long hours should be explored as well. Treatment Considerations The following is a description of couple therapy with Rachel and John using an EFT approach. The stages of EFT addressed in this case will include stabilization, building self and couple capacities, and integration. Stabilization During the initial assessment, the counselor assisted each partner in identifying and understanding their relationship patterns. Rachel was able to identify that she has difficulty monitoring and regulating her emotions, which causes her to “become upset” and isolate from John and their sons. She also was able to identify that the trauma of the loss of her first husband had not been fully addressed. Rachel identified feeling helpless because of her intense emotional responses to the re-experiencing symptoms of trauma. She also reported feeling guilty for making John feel defeated when he does not understand her traumatic memories and cannot help her through them. John identified that he feels frustrated when Rachel does not communicate with him about what she needs when she is triggered by a trauma memory. John also reported recognizing that his withdrawal response to Rachel is also triggering for her. As therapy progressed, John and Rachel developed a better understanding for one another’s emotions and expressed greater empathy for each other’s needs for safety and stability in the relationship. Building Self and Relationship Capacities During the therapeutic process, Rachel began to acknowledge that her difficulty regulating her emotions has been exacerbated by the trauma of her first husband’s death. She stated that she feels “clingy” to John because she often finds herself worried about his safety. John reported that he had “no idea” about the depths of Rachel’s grief and trauma from her first husband’s death. Rachel and John realized that they had never spoken with each other about her feelings or about what happened. He said that if he had known more about how she was feeling and why, he could have done more to be more sensitive. Exploring their own emotional experiences has helped John and

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Rachel begin to rebuild trust within their relationship. They have also been able to better identify and communicate what they need from one another. Integration Nearing the completion of the therapeutic process, Rachel and John both reported increased relationship satisfaction as they practiced communicating their experiences, emotions, and relationship needs. Rachel stated that being able to share her feelings about the loss of her first husband with John helped her feel supported and encouraged to continue talking with him about other difficult issues. John reported that Rachel’s openness helped him feel less like an “outsider in their relationship” and more capable of supporting her when she needed it. He reported that he feels more connected to her and therefore less frustrated that he does not understand how she is feeling or why. At the conclusion of the therapeutic process, both Rachel and John stated that they felt more hopeful about their relationship. They reported feeling confident in maintaining their improved communication and relationship skills. Individual Therapy In individual therapy, Rachel focused on overcoming her reticence to communicating with John and on dealing with the trauma of her first husband’s death. She had previously stated that he had never wanted to listen to her and therefore she had not felt comfortable trying to talk to him. John worked on learning different coping skills for when he feels frustrated or defeated. He also made new strategies for spending more quality time with Rachel. Clinical Outcome Overall, the clinical outcome was positive for this couple. Both partners were committed to identifying challenges and working to find therapeutic solutions. Both partners attended therapy sessions and were engaged throughout the process. Even when challenges arose, both Rachel and John exhibited a willingness to work on those challenges because of their commitment to each other. Conclusion Recovering from trauma is a complex process. For most people, in order to return to a happy and fulfilling life, they must work individually and within their relationships. From an individual standpoint, a person must learn to reconceptualize the trauma and employ more positive coping skills. Within a relationship, each person must work on communication and re-establishing intimacy to create a safe space for further growth and development. Although traumatic events can happen in any person’s life and may have profoundly negative effects, it is possible to recover and have successful, fulfilling lives with healthy relationships.

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References Alexander, P. C. (2014). Dual-Trauma couples and intimate partner violence. Psychological Trauma: Theory, Research, Practice, and Policy, 6(3), 224–231. doi:http:// dx.doi.org/10.1037/a0036404 American Psychiatric Association. (2013). Diagnostic and statistical manual for mental Disorders (5th ed.). Arlington, VA: Author. Canevello, A., Michels, V.,  & Hilaire, N. (2016). Supporting close others’ growth after trauma: The role of responsiveness in romantic partners’ mutual posttraumatic growth. Psychological Trauma: Theory, Research, Practice, and Policy, 8(3), 334–342. Childhelp. (n.d.). The issue of child abuse. Retrieved from https://www.childhelp.org/ child-abuse/ Evans, S. E., Steel, A. L., Watkins, L. E., & DiLillo, D. (2014). Childhood exposure to family violence and adult trauma symptoms: The importance of social support from a spouse. Psychological Trauma: Theory, Research, Practice, and Policy, 6(5), 527–536. Johnson, S. M., & Williams-Keeler, L. (1998). Creating healing relationships for couples dealing with trauma: The use of emotionally focused marital therapy. Journal of Marital and Family Therapy, 24(1), 25–40. Miano, A., Weber, T., Roepke, S., & Dziobek, I. (2017). Childhood maltreatment and context dependent empathic accuracy in adult romantic relationships. Psychological Trauma: Theory, Research, Practice, and Policy, 10(3), 309–318. Lambert, J., Engh, R., Hasbun, A., & Holzer, J. (2012). Impact of posttraumatic stress disorder on the relationship quality and psychological distress of intimate partners: A meta-analytic review. Journal of Family Psychology, 26(5), 729–737. Oseland, L., Schwerdtfeger Gallus, K., & Nelson Goff, B. (2016). Clinical Application of the Couple Adaptation to Traumatic Stress (CATS) model: A pragmatic framework for working with traumatized couples. Journal of Couple & Relationship Therapy, 15(2), 83–101. Taft, C., Watkins, L., Stafford, J., Street, A., & Monson, C. (2011). Posttraumatic stress disorders and intimate relationship problems: A meta-analysis. Journal of Consulting and Clinical Psychology, 79(1), 22–33. doi:10.1037/a0022196

8 THE BORDERLINE COUPLE George Stoupas

F

or some clinicians, the term “borderline” can evoke feelings of fear or hopelessness. This word can conjure images of dramatic suicide attempts, out of control aggression, or walking on eggshells. Clinicians without experience with this population may believe the widespread clinical folklore that people with Borderline Personality Disorder (BPD) cannot be treated or are limited to short-term crisis stabilization. Thankfully, this is not the case. Since the original publication of The Disordered Couple 20 years ago, there has been substantial research on Borderline Personality Disorder—perhaps more than for any other personality disorder. This research suggests that Borderline Personality Disorder is treatable and that people with this disorder can achieve lasting remission with the proper care. The same is true of couples. Dialectical Behavior Therapy (DBT)— now seen as the gold standard in BPD treatment—has been modified for the treatment of couples. This chapter addresses couple therapy for cases in which one or both members have Borderline Personality Disorder. Working with these couples can be challenging for even the most seasoned clinicians. The chapter provides a basic overview of Borderline Personality Disorder, diagnostic criteria, and prevalence. It includes a brief discussion of etiology and reviews current research regarding couples with this disorder, including assessment recommendations and treatment inventions. Systemic case conceptualizations and cultural considerations are also addressed. Finally, the chapter ends with an in-depth case study demonstrating successful couple therapy for BPD. Overview: Theory and Research on the Borderline Couple Borderline Personality Disorder affects between 1.6 and 5.9% of the general population (American Psychiatric Association, 2013). In clinical settings,

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this estimate increases to nearly 20%. Fruzzetti and Fruzzetti (2003) note that individuals with less severe problems and/or those for whom problems arise only in romantic relationships are not included in DSM estimates; they estimate that approximately 50% of the couples in their clinic exhibit significant borderline features. Despite the interpersonal instability associated with this disorder, a large number of people with BPD—up to 30%—report being involved with a romantic partner through dating, cohabitation, or marriage (Bouchard, Sabourin, Lussier, & Villeneuve, 2009). Because of this, clinicians who work with couples should have an understanding of this disorder as well as how it impacts assessment, case conceptualization, and treatment. Etiology of Borderline Personality Disorder Borderline Personality Disorder can be seen as the product of a number of factors with many possible diagnostic pathways. These include genetic and biological factors, childhood trauma, and dysfunctional patterns of communication in early caregiving relationships (Fruzzetti, Shenk, & Hoffman, 2005). The family environment can either protect against or exacerbate the effects of biological vulnerabilities. Zanarini et al. (1997) found that 92% of people with BPD surveyed report having experienced emotional neglect or denial as children. Battle et al. (2004) report that a BPD diagnosis statistically predicts the experience of parental neglect. These early caregiving relationships create the foundations for later intimate relationships. The Biosocial Transactional Model (Fruzzetti  & Fruzzetti, 2003; Fruzzetti et  al., 2005) provides a conceptualization of BPD that highlights the role of interpersonal relationships, and is therefore useful for clinicians working with BPD couples. Linehan (1993) characterizes BPD as chronic emotional dysregulation that disrupts one’s ability to think clearly and manage behavior. This dysregulation is based on vulnerability to negative emotion, emotional regulation skills deficits, and problems in how other people respond to one’s emotional expressions. In this characterization, emotional vulnerability means being particularly sensitive to emotions, as well as reacting to them quickly and intensely across situations. People with emotional vulnerability also have difficulty returning to baseline following arousal; they feel upset longer, and their emotional arousal may grow exponentially as new situations arise. These deficits are thought to be related to invalidation and overprotection by caregivers during childhood. Emotional invalidation occurs when a person’s legitimate emotional experiences are rejected as invalid or illegitimate by others. This can be done harshly, such as a parent saying “you always cry for nothing, you little baby.” It can also occur as the result of the other person’s misunderstanding or preoccupation, as in the case of a parent saying “oh, c’mon, you’re not really upset” or ignoring the child’s tears. Fruzzetti and colleagues (2005) outline other types of invalidation, including invalidation of thoughts, wants, and internal experiences, as well as invalidation of public

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behavior. Caregivers may minimize the child’s difficulties, such as in the case of expecting emotional and behavioral maturity beyond the child’s developmental level. Caregivers may also invalidate the child’s sense of self by questioning his or her perceptions of events, causing confusion between what the child feels and what others feel, as in the case of parental over involvement. According to Sperry (2016b), BPD subtypes are related to different parenting styles: parental overprotectiveness leads to dependence, demandingness leads to histrionic behavior, and inconsistency leads to passiveaggressiveness. In general, these experiences result in adults with self-views that state “I don’t know where I am or where I’m going” (p. 105). For people with BPD, self-esteem, interests, values, and loyalties fluctuate depending on their mood. Dysfunctional family environments teach children self-destructive and self-defeating coping strategies like aggression, impulsive emotional outbursts, and threats of self-harm. The experience of abuse and/or abandonment leads to fluctuating idealization and devaluation of significant others, as well as seeing oneself as defective and unworthy. BPD in Romantic Relationships In adults with Borderline Personality Disorder, these types of developmental experiences set the stage for intimate relationships in terms of how these they interpret their partners’ behavior and respond. In general, people with BPD have a lower probability of being married, more breakups, and significant dysfunction in romantic relationships compared to other personality disorders (Bouchard & Sabourin, 2009). Montigny-Malenfant et al. (2013) examined the interactions of couples in which the female partner had BPD. They found that these couples exhibited significantly more negative behaviors than community control couples. These included controlling the discussion, criticism, blaming, and threats. Miano, Grosselli, Roepke, and Dziobek (2017) found that women with BPD exhibited more stress compared to their partners, felt more relationship insecurity, and were more hostile than healthy controls. These researchers attributed the differences to a heightened stress response, which predicted more negative communication patterns and more perceived distance from partners. Bouchard et al. (2009) also found significantly higher rates of rejection anxiety as well as physical and psychological violence—both as perpetrator and victim. Bouchard and Sabourin (2009) provide a summary analysis of research regarding couple dysfunctions in Borderline Personality Disorder. Overall, these couples report less relationship satisfaction and more distress. In terms of sexual functioning, there are often problems such as heightened sexual impulsivity, reduced satisfaction, boredom, greater preoccupation with sex, and, conversely, sexual avoidance. Sexual problems were more likely to be reported by women with Borderline Personality Disorder compared to men. Women with BPD report earlier age of first intercourse and more lifetime

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sexual partners, and were more likely to have been the victims of date rape. People with this disorder may view sex as a means to secure relationship commitment and avoid rejection. Partner choice has a significant impact on overall well-being and functioning, as partners who are psychologically healthy can stabilize the relationship. Unfortunately, those with this disorder typically have poor judgment when it comes to choosing mates. Behaviors associated with BPD, like aggression, drug and alcohol abuse, and self-harm, discourage healthy individuals from entering into intimate relationships with those who have this disorder. Bouchard et al. (2009) found a high rate (55.9%) of personality disorders in the partners of borderline women, compared to DSM-5’s estimated rate of 15% in the general population. Lavner, Lamkin, and Miller (2015) examined 172 community newlywed couples and conducted followup analyses over a period of ten years. They found that people with BPD symptoms tended to have partners with similar symptoms, lending support to the idea that people with this disorder practice some degree of assortative mating. They also found that difficulties present at the beginning of the marriage tended to persist over time; however, these difficulties did not predict divorce. The authors speculate that couples may simply adapt to the dysfunction, or that those with BPD symptoms may be reluctant to leave troubled relationships for fear of being alone. DSM-5 and the Borderline Couple The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) describes Borderline Personality Disorder as “a pattern of pervasive instability in interpersonal relationships, self-image, and affects, and marked impulsivity” (American Psychiatric Association, 2013, p. 663). Symptoms of this disorder include frantic efforts to avoid abandonment, a pattern of intense relationships in which other people are idealized or devalued, unstable self-image, recurrent suicidal gestures, impulsivity, intense anger, paranoia, emotional reactivity, and feelings of emptiness. People with BPD frequently engage in risky, impulsive behavior—such as spending money, abusing drugs and alcohol, or sex with strangers. Additionally, stress-related paranoia (e.g., about a partner’s infidelity—real or imagined) may give way to dissociation. This diagnosis frequently co-occurs with other disorders, including Major Depression, Substance Use Disorders, and Post-Traumatic Stress Disorder. DSM-5 and Assessment Considerations Given the potential for emotional volatility, some clinicians may wonder whether couple therapy is appropriate for those with Borderline Personality Disorder. Links and Stockwell (2001) suggest that couple therapy actually has unique advantages over individual interventions for these clients.

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They recommend that clinicians conduct an extensive clinical history to determine which of the three following clusters best describes the borderline member of the couple: impulsive, identity, or affective (described below). The “impulsive” cluster is characterized by chronic self-destructive and otherwise harmful behaviors. This includes suicide threats and/or attempts, aggression, and substance abuse. Those who fall into this category often have difficulty maintaining relationships over a significant period of time because of these destructive behaviors, and typically report instability in their previous treatment relationships and multiple premature terminations. Because of this, Links and Stockwell (2001) suggest that individual therapy is more appropriate for these clients. It can work to decrease impulsive behaviors and develop improved coping skills. Partners can be involved to establish a safety plan and address their own needs. Once the partner with BPD makes sufficient progress and can cope with couple therapy without acting out, then it can be initiated. Clients with Borderline Personality Disorder who fall into the “identity” cluster have chronic feelings of emptiness, significant difficulty being alone, and disturbance of identity. Lacking a stable sense of self, these people depend on others to define themselves. Though crises and conflicts frequently occur, the borderline partner remains deeply committed to the relationship. According to Links and Stockwell (2001), this kind of relationship is the best candidate for couple therapy. Through a safe and supportive therapeutic environment, the goal is to achieve a more stable sense of self independent of the other person, thereby changing the dynamics of the relationship. Finally, the “affective” cluster consists of individuals who experience intense and unstable emotions, particularly anger. These emotions are usually inappropriate to the situation and excessively intense. This affective intensity triggers out of control behaviors, which lead to chaotic relationships. Coupled with a psychologically healthy person, people in this cluster have a safe receptacle for their emotions. The healthy partner will tolerate these intense emotions if the borderline partner meets some of his or her emotional and/or physical needs. Links and Stockwell (2001) suggest that couple therapy can be effective with these couples when the healthy partner receives education about how to diffuse high intensity situations, establish boundaries, and practice self-care. The case example at the end of this chapter describes a couple representing this cluster. Case Conceptualizations: Individual and Couple According to Sperry (2010a), case conceptualization is “a clinical strategy for obtaining and organizing information about a client, explaining the client’s situation and maladaptive patterns, guiding and focusing treatment, anticipating challenges and roadblocks, and preparing for successful termination” (p. 110). Case conceptualization seeks to understand the individual’s

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presenting problem in the context of other factors like developmental history, culture, interpersonal relationships, and health, among many others. This clinical competency can be approached from both the individual and systemic perspectives. Individual Case Conceptualization A major component of individual case conceptualizations is the client’s personality dynamics and maladaptive pattern. The optimal criteria for Borderline Personality Disorder is “frantic efforts to avoid real or imagined abandonment” (Sperry, 2016b, p. 105). People with Borderline Personality Disorder are often triggered by fear of losing close relationships or failing to meet expectations for personal goals. They harbor maladaptive schemas regarding abandonment, personal defectiveness, lack of self-control, and abuse or mistrust with others. People with this disorder have a rigid and inflexible way of thinking, and have difficulty learning from experiences. Couple Case Conceptualization Similar to the individual case conceptualization, the purpose of a couple case conceptualization is to understand the couple’s presenting problem, origin of their distress, and pattern of interaction, as well as to develop a focused treatment plan. Sperry (2016a) defines family case conceptualizations as case conceptualizations that incorporate systemic dynamics. These may include specific details about the couple, parental, or sibling subsystem. They may also include information about communication, such as how people in the system negotiate, how they share power, or their level of intimacy. In completing a couple case conceptualization that involves Borderline Personality Disorder, clinicians should examine the developmental experiences for each partner as well as systemic dynamics in the present couple. Ideally, the couple case conceptualization will include both of these. Benjamin’s Structural Analysis of Social Behavior (2003a) provides a useful framework for understanding the interpersonal dynamics of this dis­ order. According to this framework, people with BPD typically come from chaotic and dramatic family environments. Trauma, abandonment, i­ solation, rejection, and emotional, physical, and/or sexual abuse is common. These experiences become internalized, teaching the person that he or she is a bad person and that other people are to be idealized or scorned, sometimes in rapid succession. Unhealthy family rules suggest that autonomy is dangerous. Safety means remaining dependent on the dysfunctional family system at all costs. Collective misery is preferable to separation; in fact, sickness, dysfunction, and disability actually elicit love and caregiving from others. As adults, people who grew up in this kind of family environment maintain the belief that intimate relationships are built on misery. They believe that romantic partners want and need chaos and dependency.

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Those who enter into romantic relationships with people who have Borderline Personality Disorder may have a wide range of psychological health or dysfunction. People with certain personality dynamics are often attracted to those with BPD, particularly Narcissistic Personality Disorder (Lachkar, 1998). Seemingly healthy individuals whose physical or emotional needs are met by the BPD partner are likely to enter and stay in these relationships despite problems. For example, a man with low self-esteem may tolerate the emotional instability of a borderline woman because she makes him feel better about himself. Similarly, people with dependent personality styles or those who engage in pathological caretaking may be drawn to the endless crises and needs the borderline partner offers. Those with substance use disorders may stay in with borderline partners for the sake of maintaining the addiction, especially if the partner is also addicted. Fruzzetti and Fruzzetti (2003) note that borderline problems are particularly acute in couples presenting for therapy. This disorder’s hallmarks of emotional volatility and intensity may be expressed as jealousy, paranoia, or suicidal and violent gestures intended to avoid abandonment. Communication between the partners is a major focus of treatment, as providing nurturance at inappropriate times may serve to reinforce these destructive patterns. Because of the complex and fluctuating nature of these relationships, couple therapists can expect a wide variety of presenting problems and precipitating events when working with borderline couples. Cultural Considerations Clinicians who work with couples should be aware of each partner’s cultural identity as well as how culture influences or explains the presenting problem(s). The cultural formulation component of a case conceptualization is a way to organize this information and answer the “What role does culture play?” question (Sperry, 2010a, p. 112). According to DSM-5, symptoms related to Borderline Personality Disorder are found in different cultures throughout the world (American Psychiatric Association, 2013). Normative developmental experiences during adolescence and early adulthood, such as substance use, emotional instability, and changes in identity with regard to sexual orientation, values, or purpose in life, may be misinterpreted as signs of this disorder. This disorder is most often diagnosed in early adulthood, with the greatest impulsivity and emotional instability during that period of life. As people with BPD age, the intensity of these symptoms typically decreases, and they can achieve greater stability in interpersonal relationships. Those diagnosed with Borderline Personality Disorder are overwhelmingly female—around 75%; however, clinicians should be aware of gender biases in interpreting healthy behavior and be careful not to overlook these symptoms in males despite this imbalance.

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Paris (1996) suggests that differences in the diagnostic prevalence of Borderline Personality Disorder among cultures internationally may be due to variations in levels of industrialization, social cohesion, and family structure. He notes that BPD tends to be more prevalent in North America, especially in large, “Westernized” cities. Paris (1996) speculates that less industrialized, “traditional” societies place greater emphasis on social cohesion. In these societies, children raised in the type of dysfunctional families that are likely to produce BPD are shielded from some of the negative effects because they have the opportunity for secure attachments with other people in extended social support networks. As family relationships and connection to the community are compromised, borderline pathology becomes more likely. Paris (1996) notes that people who emigrate from less developed to more developed areas (e.g., from Central America to the United States) are at greater risk of developing this type of psychopathology. Clinicians who work with couples would do well to pay close attention to each partner’s level of acculturation, immigration history, and cultural identity factors. High levels of acculturation typically mean that personality dynamics better explain the presenting problem(s). However, in couples in which one or both members have low levels of acculturation, cultural factors may be more operative. Expectations about commitment, expression of affection, communication, and other core features of romantic relationships may be partly or wholly explained by culture. Treatment Considerations: Dialectical Behavior Therapy (DBT) Since Marsha Linehan’s original work with chronically suicidal patients, Dialectical Behavior Therapy (DBT) has been the focus of a growing body of research and is now considered by many to be the gold standard treatment for Borderline Personality Disorder. DBT has since been adapted to the treatment of couples who exhibit borderline characteristics or where one or both members have this disorder (Fruzzetti, 2006; Fruzzetti  & Fruzzetti, 2003). As with DBT for individuals, this treatment is based on several theoretical principles related to dialectical philosophy. In order for treatment to be successful, contradictions, or tension points, within the relationship need to be resolved (i.e., synthesized). They include: closeness versus conflict; partner acceptance versus change; one partner’s needs versus the other’s needs; individual satisfaction versus relationship satisfaction; and intimacy versus autonomy. Despite the apparent opposition between these points, the goal of DBT is to achieve both—not with compromise, but with synthesis. This is accomplished in a validating, affirming therapeutic environment that does not pathologize the borderline partner’s desire for closeness or intimacy but rather keeps health and balance as the core goals.

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DBT Components As with DBT for individuals, DBT for couples includes multiple types of interventions, which can be delivered individually or conjointly depending on the couple’s needs. These are: skill acquisition or enhancement; skill generalization; client motivation/behavior change; therapist capability enhancement and motivation; and structuring the environment (Fruzzetti & Fruzzetti, 2003). Skill acquisition or enhancement As previously outlined, people with Borderline Personality Disorder have significant deficits in self-regulation and interpersonal skills. This component of the DBT program is designed to assist both partners in developing these. Even if one partner is relatively healthy, he or she will benefit from increased capacity to self-regulate emotions to tolerate emotional volatility in the borderline partner and learn new relationship skills to manage interactions. Individual skills include: mindfulness, emotion regulation, distress tolerance, and interpersonal effectiveness. DBT for couples also includes additional skills. These are relationship mindfulness, validation, problem management, and acceptance and closeness. Skill Generalization This component of DBT for couples involves transferring the skills gained in therapy to life at home and elsewhere. This is accomplished through structured learning and practice activities, homework, and occasional telephone coaching when needed. The clinician may ask the couple to recreate arguments or conflicts during the session in order to assess problem interaction patterns and provide live coaching in the safe, structured environment of the therapy room. Behavior and Motivation Change The DBT program draws heavily from behavioral therapy (Hoffman, Fruzzetti, & Swenson, 1999). This component addresses the conditions surrounding the development and maintenance of the couple’s problems, as well as the conditions necessary to achieve positive changes. The clinician will assist the couple in identifying the antecedents and consequences connected to dysfunctional and destructive behaviors. Chain analyses are conducted throughout treatment to identify these factors. Daily diary cards or other forms of self-monitoring can be used to help the clinician assess individual and interpersonal functioning in between sessions and set new targets for the future. Therapist Motivation and Skills Working with clients who have Borderline Personality Disorder is often emotionally taxing for the clinician. Threats of suicide, violence, complex

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problems, and emotional reactivity are difficult to experience—whether they occur in an individual client or a couple. This component of the DBT program involves regular peer consultation meetings where clinicians can further develop their own skills, get alternative perspectives, and collaborate with other providers to prevent confusion, triangulation, or conflict. Structuring the Environment The final component of treatment involves identifying and eliminating environmental factors that undermine positive change. For example, the borderline partner may only receive emotional support when he or she is in crisis, or the couple may only receive professional support and guidance when symptomatic. The goal of structuring the environment is to incentivize positive change as opposed to maintaining the dysfunctional status quo. Stages of DBT Treatment DBT for couples is organized into distinct stages, each with specific treatment targets (Fruzzetti & Fruzzetti, 2003). Pretreatment As in many other forms of individual and couple therapy, this stage consists of an orientation to treatment. This includes a discussion about pros and cons, treatment duration, and treatment alternatives. It also includes collaboration regarding the problem severity hierarchy and initial assessments. The couple is also asked to begin self-monitoring at this time. This stage may take two or three sessions, ending with a formal treatment agreement. Stage 1 During this stage, behaviors that negatively impact safety and stability are targeted. These include: life-threatening behaviors, such as violence or self-injury; therapy-interfering behaviors, like non-compliance or nonattendance; and life-interfering behaviors, such as substance abuse, infidelity, illegal activities, or any other behaviors that limit quality of life. In this stage, partners are taught self-management skills as well as how to generalize them to new situations. For more extreme life-threatening behaviors, individual therapy should remain the core treatment until the borderline partner is stable; however, couples interventions can be used to augment individual work during this time. At this stage, couples interventions typically include some form of psychoeducation about Borderline Personality Disorder and the roles of emotional regulation and invalidation. As the borderline partner completes individual work, the other partner can work on providing appropriate validation while avoiding criticism. Together, the couple can begin to work on self-management and distress tolerance strategies, such as time-outs.

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Stage 2 This stage focuses on emotional awareness—both for oneself and one’s partner. For couples with BPD, the ability to accurately label emotions is often not present or significantly impaired. The borderline partner may experience negative feelings like anger but have little awareness of the reason behind it. Furthermore, this partner’s inability to express these feelings in healthy ways can lead to more conflict and invalidation from the other person. In Stage 2 of DBT for couples, awareness of oneself and one’s partner is cultivated through mindfulness, self-disclosure, and labeling and expressing emotions. Validation skills help partners listen to one another, reflect back emotions, and pick up on unstated needs and desires. This helps contextualize problems, normalize behavior, and maintain a spirit of equality and reciprocation (Hoffman et al., 1999). During this stage, relationship activation interventions involve the couple doing enjoyable things together (e.g., going out to dinner), as borderline couples often stop interacting for fear of setting off a conflict. For partners who have histories of abuse and trauma, Stage 2 also involves some form of exposure therapy to address related symptoms. Although this is done individually, the partner plays an important role in providing emotional support throughout the process. Stage 3 By this stage, the couple has achieved safety and stability, and possesses some capacity to validate one another’s feelings and spend pleasurable time together without the constant threat of conflict. Stage 3 is focused on fine tuning problem-solving strategies and further changing unhealthy and/or destructive interaction patterns. Problem management integrates mindfulness, validation, and emotional expression skills to find healthy solutions to problems as they arise. Additionally, the couple can begin redefining their own criteria for what is considered a “problem.” Through the use of video recording and live clinician observation, the couple can identify dysfunctional patterns and practice alternative responses. Here, the clinician plays the alternating roles of teacher, coach, and traffic cop (Fruzzetti & Fruzzetti, 2003), explaining and encouraging the use of new skills while slowing down or stopping the pace of interaction when needed. Stage 4 In this final stage, couples work to synthesize the competing demands of intimacy and autonomy. This stage involves the use of mindfulness and distress tolerance skills to reach “radical acceptance” about new conflicts and problems. Partners learn to let go or accept differences that will not soon change, as well as identify how their own responses exacerbate problems. As each partner becomes better equipped at managing their own thoughts and feelings, they are able to tolerate closeness as well as separateness. Through

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the practice of self-disclosure and validation, the couple enhances intimacy. This intimacy is strengthened by each partner’s newfound independence. The borderline partner begins to see that time apart is not abandonment and experiences satisfaction in caring for herself. Similarly, the other partner begins to move closer because he no longer feels suffocated or afraid of failing to meet unreasonable demands. Together, the couple begins to recognize that independence and intimacy are not mutually opposed but instead reinforce one another. The couple spends the final months of treatment practicing these new skills, soliciting feedback from the clinician less frequently and only in situations they could not manage on their own. Case Example: Melanie and Jim Melanie and Jim had been married for three years. Following Melanie’s discharge from an inpatient psychiatric unit, a case manager referred them to couples counseling. Melanie was involuntarily hospitalized after neighbors called the police to their apartment. When the police arrived, they found Melanie heavily intoxicated, punching Jim, and screaming that he was having an affair. Jim admitted that he had also been drinking and told the police that this happens regularly. Because Melanie had threatened to kill herself, the police transported her to the local hospital’s psychiatric unit. Melanie was an attractive, 37-year-old Caucasian American woman. She was unemployed and financially dependent on Jim, claiming that she was unable to due to chronic migraines. This hospitalization was just the most recent of many throughout her lifetime. Melanie had a long history of emergency department visits and police intervention. She had been previously diagnosed with Bipolar Disorder and Alcohol Use Disorder, though she never followed up with treatment recommendations. Jim was a quiet, passive 44-year-old Caucasian American man who worked as a groundskeeper for the city’s public works department. While Jim did not have nearly the same level of dysfunction in his personal history, he struggled with depression and alcoholism throughout his life. He and Melanie originally met at a bar and quickly became romantically involved. Melanie initially expressed deep affection for her “strong, silent man.” They found common ground in their love of country music and drinking and moved in together soon after they met. Conflicts arose shortly after this. Melanie often expressed intense jealousy of other women and accused Jim of planning to leave her. She was physically abusive and often referred to him as a “piece of shit loser.” These conflicts were intensified by alcohol, as often one or both partners were drinking. Over the past few years, Jim began to withdraw and spend more time at work. He became less willing to tolerate Melanie’s outbursts and frequently criticized her. Following this recent hospitalization, Jim threated to finally leave Melanie unless she agreed to therapy.

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Assessment Considerations The assessment included comprehensive clinical interviews with both Melanie and Jim, as well as an assessment of their dynamics as a couple. Melanie Melanie was the youngest of three half-siblings and the only biological child from her father’s second marriage. Growing up, she was scorned by her other siblings because she was their father’s favorite. Melanie’s father considered her his “princess.” However, he was often physically abusive to her and other family members when enraged. Melanie’s mother worked as a bartender, and Melanie often spent late nights at the bar with her. Melanie described her mother as an emotionally unavailable alcoholic. She reported that she was raped by one of the bar patrons as a teenager but was accused of making the story up when she told her parents. Prior to meeting Jim, Melanie had a number of chaotic relationships with other men that included physical violence and, on two occasions, failed suicide attempts. She had been using alcohol since age 16 and drank to intoxication several times per week. Jim Jim was adopted and the only child of two hardworking professionals. Growing up, he was quiet and withdrawn. He reported that his parents were good material providers, but did not provide much emotional comfort. Jim described feeling “ugly” and “different” throughout his childhood. He seemed to be drifting through life along the path of least resistance. Prior to Melanie, Jim’s sole significant romantic relationship was with a woman who left him for another man. He had been using alcohol since his early 20s as a way to socialize with others. DSM-5 Melanie met DSM-5 criteria for Borderline Personality Disorder and moderate Alcohol Use Disorder. She also had trauma-related symptoms. Jim met the criteria for mild Alcohol Use Disorder with some depressive symptoms. He was just below the threshold for dependent personality disorder. Case Conceptualization: Individual and Couple Individual Case Conceptualization Melanie’s emotional and interpersonal problems can be understood in light of the invalidation and emotional, physical, and sexual abuse she experienced during childhood. She learned that other people can be the source of great safety and love, but this can change quickly to hurt and betrayal. Melanie’s drinking can be seen as a means to self-medicate her emotional distress. She

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had become increasingly scared of being abandoned by Jim, and her hostility towards him was, paradoxically, an attempt to keep him involved. Her maladaptive pattern was identified as lashing out when threatened by separation or abandonment. Jim’s behavior can be understood in light of his low self-esteem and dependent personality style. He felt unworthy of love and was willing to tolerate instability and abuse in order to be with someone. Jim’s childhood experience of adoption and emotionally distant parents caused him to question his worth and seek safety in a relationship. His depression and drinking were responses to his negative self-view, the latter of which helped him connect with others and alleviate his discomfort. Couple Case Conceptualization Melanie and Jim appeared to be bound together in an unsatisfying but safe arrangement where both partners benefitted in specific ways. Melanie received financial support and steady affection from a person who would tolerate her emotional outbursts and abusive behavior. When she felt angry or threatened (especially while intoxicated), her outbursts served to elicit Jim’s caregiving and reassurance, which further reinforced this pattern. For Jim, the relationship provided proof that he was worthy of love. Melanie’s physical attractiveness was an added bonus. For most of the relationship, he was willing to tolerate turmoil and abuse in order to have someone. Melanie’s dominance complimented Jim’s passivity. In their relationship, alcohol served as a way to bond, though it often led to more conflict. Over the past year, Jim started to question whether he wanted to stay with Melanie. His parents had become increasingly vocal about him ending the relationship, and Jim responded by becoming resentful and critical of Melanie. Cultural Considerations Both Melanie and Jim were highly acculturated with no signs of acculturative stress. Their problems—both individually and as a couple—were attributed to personality dynamics rather than cultural factors. Melanie’s explanatory model for the couple’s conflicts was that Jim was not sufficiently committed to her, whereas Jim believed that Melanie was “just a really intense person” and “crazy sometimes.” Treatment Given the couple’s dynamics and presenting problems, a modified course of dialectical behavior therapy was indicated. Melanie and Jim were oriented to DBT and commenced Stage 1. Both partners examined their alcohol use and how it contributed to their relationship problems. This served as a vehicle to discussing self-management generally in other areas of their lives. During

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this stage, they also learned about Borderline Personality Disorder. Melanie spent time in individual therapy working on distress tolerance skills, while Jim practiced new ways to support and validate her. Once safety and stability in their daily lives had been achieved, the couple moved on to Stage 2, where they worked on relationship mindfulness and effective self-disclosure. They planned activities together, including dinners and attending a concert. With the clinician’s guidance, Melanie worked on identifying and sharing how she was feeling in the moment. She explained that her destructive behavior is the result of fears about Jim leaving her. Jim explained that he loves her, but withdraws because he does not know what else to do. Chain analyses helped identify specific steps in ongoing conflicts and helped the couple consciously choose alternative responses. During this time, Melanie also addressed trauma regarding the sexual assault she suffered as a teenager. In Stage 3, the couple focused on ongoing problem areas and how to approach these in a better way. For example, Melanie’s anger and fear surrounding Jim’s long work hours was reframed as a desire to spend more quality time with him. Jim recognized that his typical response—pulling away— only served to make matters worse. By watching themselves argue on tape and listening to the clinician’s coaching, the couple developed new ways of interacting. When Melanie felt insecure, she voiced her fears without making accusations or being abusive. Jim responded by showing affection and making time for her, thereby reinforcing healthy responses. Finally, in Stage 4, the couple explored the relationship between intimacy and autonomy. Melanie registered for a photography class at the local college, while Jim joined a bowling league with other men from work. This time apart complimented time spent together, which now consisted of pleasurable activities instead of simply drinking. Jim no longer felt attacked by Melanie, though she sometimes needed time to work through her feelings with his support. In total, treatment lasted about one year with sessions spread throughout. Following termination, the couple returned for consultation and support as needed. Conclusion This case illustrates the key elements of couple therapy with Borderline Personality Disorder. This includes assessment, diagnosis, individual and couple case conceptualization, cultural factors, and treatment according the DBT model. Couples with Borderline Personality Disorder can be challenging, both personally and professionally. Successful treatment depends on understanding the origins of this disorder and how it manifests in romantic relationships. If the borderline partner’s behavior can be viewed as a sincere desire for intimacy rather than being pathologized or invalidated, then the

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couple can begin to synthesize the competing demands of closeness and separateness using new skills. References American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Alexandria, VA: Author. Battle, C. L., Shea, M. T., Johnson, D. M., Yen, S., Zlotnick, C., Zanarini, M. C., . . . Morey, L. C. (2004). Childhood maltreatment associated with adult personality disorders: Findings from the Collaborative Longitudinal Personality Disorders Study. Journal of Personality Disorders, 18(2), 193–211. doi:10.1521/pedi.18.2.193.32777 Benjamin, L. (2003a). Interpersonal diagnosis and treatment of personality disorders (2nd ed.). New York, NY: Guilford Press. Bouchard, S.,  & Sabourin, S. (2009). Borderline personality disorder and couple dysfunctions. Current Psychiatry Reports, 11, 55–62. doi:10.1007/s11920-1100910009-x Bouchard, S., Sabourin, S., Lussier, Y., & Villeneuve, E. (2009). Relationship quality and stability in couples when one partner suffers from borderline personality disorder. Journal of Marital and Family Therapy, 35(4), 446–455. doi:10.1111/j.17520606.2009.00151.x Fruzzetti, A. E. (2006). The high-conflict couple: A dialectical behavior therapy guide to finding peace, intimacy, and validation. Oakland, CA: New Harbinger. Fruzzetti, A. E., & Fruzzetti, A. R. (2003). Borderline personality disorder. In D. K. Snyder & M. A. Whisman (Eds.), Treating difficult couples: Helping clients with coexisting mental and relationship disorders (pp. 235–260). New York, NY: Guilford Press. Fruzzetti, A. E., Shenk, C.,  & Hoffman, P. D. (2005). Family interaction and the development of borderline personality disorder: A transactional model. Development and Psychopathology, 17, 1007–1030. doi:10.1017/S0954579405050479. Hoffman, P. D., Fruzzetti, A. E.,  & Swenson, C. R. (1999). Dialectical behavior therapy—Family skills training. Family Process, 38(4), 399–414. Lachkar, J. (1998). Narcissistic/borderline couples: A  psychodynamic approach to conjoint treatment. In J. Carlson  & L. Sperry (Eds.), The disordered couple (pp. 259–284). Bristol, PA: Brunner/Mazel. Lavner, J. A., Lamkin, J., & Miller, J. D. (2015). Borderline personality disorder symptoms and newlyweds’ observed communication, partner characteristics, and longitudinal marital outcomes. Journal of Abnormal Psychology, 124(4), 975–981. doi:10.1037/abn0000095.supp Linehan, M. M. (1993). Cognitive–behavioral treatment of borderline personality disorder. New York, NY: Guilford Press. Links, P. S., & Stockwell, M. (2001). Is couple therapy indicated for borderline personality disorder? American Journal of Psychotherapy, 55(4), 491–506. Miano, A., Grosselli, L., Roepke, S., & Dziobek, I. (2017). Emotional dysregulation in borderline personality disorder and its influence on communication behavior and feelings in romantic relationships. Behavior Research and Therapy, 95, 148– 157. doi:10.1016/j.brat.2017.06.002 Montigny-Malenfant, B., Santerre, M., Bouchard, S., Sabourin, S., Lazarides, A., & Belanger, C. (2013). Couples’ negative interaction behaviors and borderline

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personality disorder. The American Journal of Family Therapy, 41(3), 259–271. doi:10.1080/01926187.2012.688006 Paris, J. (1996). Cultural factors in the emergence of borderline pathology. Psychiatry, 59(2), 185–192. Sperry, L. (2010). Highly effective therapy: Developing essential clinical competencies in counseling and psychotherapy. New York, NY: Routledge. Sperry, L. (2016a). Teaching the competency of family case conceptualizations. The Family Journal, 24(3), 279–282. doi:10.1177/1066480716648315 Sperry, L. (2016b). Handbook of diagnosis and treatment of DSM-5 personality disorders: Assessment, case conceptualization, and treatment. New York, NY: Taylor & Francis. Zanarini, M. C., Williams, A. A., Lewis, R. E., Reich, R. B., Vera, S. C., Marino, M. F., . . . Frankenburg, F. R. (1997). Reported pathological childhood experiences associated with the development of borderline personality disorder. American Journal of Psychiatry, 154(8), 1101–1106. doi:10.1176/ajp.154.8.1101

9 THE NARCISSISTIC COUPLE James Morris III

T

Background of Narcissistic Personality Disorder

he concept of narcissism has been dated back to ancient Greek myths (Pincus  & Lukowitsky, 2010). Narcissism can be conceptualized as an individual’s ability to retain a positive self-image through various different regulatory processes, while constantly striving for validation and affirmation (Pincus & Lukowitsky, 2010). Research suggests that the prevalence rate of Narcissistic Personality Disorder (NPD), a subset of Antisocial Personality Disorder (APSD), in the U.S. population is approximately 6.2%, with rates slightly higher for men than in women (Stinson et al., 2008). Additionally, rates of NPD are higher among males and females that are separated, divorced, or widowed. NPD is also often comorbid with Borderline Personality Disorder and Histrionic Personality Disorder (Caligor, Levy, & Yeomans, 2015). The DSM-5 characterizes individuals with NDP as individuals with an unremitting pattern of attention seeking and emotionality (American Psychiatric Association, 2013). Typically, they draw attention to themselves with the way they dress. Their manner of speech tends to be impressionistic with few details. These individuals are easily influenced by others or circumstances, which includes perceiving relationships as more intimate than they really are, leading to many relationship problems (American Psychiatric Association, 2013). NPD is said to be triggered by feelings of anger and social rejection (Dimaggio, 2012). When mistakes or shortcomings start to become unavoidable, after blaming others as much as possible, it is likely for individuals with NPD to become depressed; the risk for suicide increases among individuals with NPD as they get older. These individuals may also have developed narcissistic traits if their parents modeled ineffective attachment and lack of empathy

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and affect when they were a child. Authoritarian parenting, overuse of praise, and focus on status and success may also be a trigger for NPD (Dimaggio, 2012). Couples with Narcissistic Personality Disorder Relationships involving individuals with NPD can be tumultuous (Brunell & Campbell, 2011). Narcissists are usually charming, attractive, and extraverted, which makes them a seemingly great fit for a relationship. However, the relationship is shallow and superficial; relationships play a specific role in the narcissist’s life, where the focus is on the label of being in a relationship, and how that relationship maintains their self-esteem, as opposed to focusing on the communion with another person. Problems can arise among couples with NPD because individuals with NPD tend to be uncomfortable in situations where they cannot be the center of attention, and they have a constant need for admiration. Additionally, their emotional reactions tend to be shallow and rapidly shifting; they are dramatic and overly exaggerate their emotions. They often engage in provocative and inappropriate seductive sexual behavior (American Psychiatric Association, 2013). Furthermore, the relationship plays a part of the reinforcing system for the narcissist, and when going well, relationships can lead to inflated pride and self-esteem, also known as narcissistic esteem (Brunell & Campbell, 2011). Also, as part of the system, individuals with NPD use others for domination and for targets of blame. Individuals with NPD are essentially in love with themselves (Lachkar, 1998) and use others as instruments to maintain their narcissistic esteem (Brunell & Campbell, 2011). This reinforcement system has been referred to as the Contextual Reinforcement Model (Campbell & Campbell, 2009). Narcissists strive to be likeable, in many scenarios by many people. Although charming at first, they are usually less likeable over time because they are overly confident and make risky decisions. The partner in the relationship is crucial to this reinforcement system. The partner often has a positive relationship with the narcissist initially and then becomes cognizant of the detrimental impacts the narcissist has on their life. Unfortunately, narcissists’ behaviors tend to become more negative as time progresses; therefore, their partners also experience more negativity over time. As a result, individuals with NPD repeatedly seek new relationships that will maintain their narcissistic esteem instead of staying in relationships that do not (Campbell & Campbell, 2009). Research is lacking in regard to effective couples treatments for individuals with NPD (Links & Stockwell, 2002). Researchers have found that a stable romantic relationship does positively impact the symptoms and outcomes of NPD (Links & Stockwell, 2002). Links and Stockwell (2002) also found that there are some key characteristics that can identify NPD couples that will not likely benefit from couple therapy: the likelihood for the NPD patient to act

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out; the NPD patient’s narcissistic vulnerability and defensiveness, and the couple’s cyclical narcissistic gratification. Types of treatment for individuals with NPD will be discussed later in this chapter under the Treatment section and within the Case Study section. Caligor et al. (2015) presented two case studies of patients with NPD that are great examples of the impacts of NPD on one’s life and relationship with their partner. The first case study involved a man in his early 40s. He initially sought treatment because of reported problems with his wife. He was not attracted to his wife, had multiple other partners who he had supported financially and replaced, and thought he might be better off with someone else. He also reported being a successful entrepreneur and was highly competitive. Importantly, the client was overly confident and made poor decisions which impacted his marriage. The second case study involved a man in his early 30s. He had a history of substance abuse problems and bullied his physician when attempting to gain access to pain medication prescriptions. He also had claimed to have a girlfriend; however, when the physician contacted her, she noted that she had ended the relationship with the patient. He had exploited others financially and was unable to find stable employment after being fired from his last job. Notably, this client had inflated expectations for himself as well as exaggerated ideas about his relationship (Caligor et al., 2015). In conclusion, NPD can be presented differently for different people; however, there are key characteristics that are typically exhibited, such as inflated self-esteem, self-absorption, and little regard for others. Children of Couples With Narcissistic Personality Disorder Often, parents with NPD will focus on their own wants and needs rather than the needs of their children (Ehrenberg, Hunter, & Elterman, 1996). For instance, research has shown that when parents are on the same page and are more agreeable, as opposed to looking out for their own interests, they are less narcissistic, more empathetic, and more child-oriented. Additionally, narcissism was shown to directly impact parents’ empathy levels regardless of their level of agreeableness; perspective-taking did not matter as much as narcissistic personality traits. Child-centered parents were found to be less narcissistic as well (Ehrenberg et al., 1996). Rappoport (2005) suggests that many people, including spouses, partners, and children, learn to adapt to living with someone with NPD; this is referred to as co-narcissism, where an individual promotes narcissistic behaviors of another person. Co-narcissism enables the narcissist and feeds into the cycle of negative behaviors and thoughts. Rappoport (2005) suggests that co-narcissism is a method for children to adapt to their parent or parents’ narcissism. It is also not uncommon for narcissists to report having parents that are narcissists; as well, this suggests that children of NPD parents may develop NPD themselves. This may be partially due to the lack of predictability that

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comes with relationships with individuals with NPD (Berg-Nielsen & Wichstrom, 2012). As noted previously, triggers of NPD can include growing up as a child with parents who are grandiose and focus on status and success; therefore, having a parent that has NPD, and likely those characteristics, may set a child up to follow the path of their parent (Dimaggio, 2012). NPD parents may expect specific behaviors from their children, because they see their children as extensions of themselves; they use children as a tool (like they use their partners) to meet their own psychological and emotional needs (Rappoport, 2005). NPD parents may therefore be overly intrusive in their child’s life to meet their own selfish needs, but disregard components of their child’s life that do not interest them. The NPD parent strives to enforce their own narcissistic needs, and if their child is unable to do this, it is likely that NPD parents will punish their children; punishment can include physical and psychological abuse as well as blame and withdrawal (Rappoport, 2005). Not surprisingly, children of NPD parents tend to feel they are overly responsible for the needs of others (Rappoport, 2005). They feel that everyone has needs similar to their narcissistic parents and that the needs of others need to be met immediately. Furthermore, because of the urgent need to appease others, children of NPD parents often neglect their own needs and feelings and become very insecure with low self-esteem. Common selfconcepts of children of NPD parents include feelings that they are insensitive, selfish, defective, afraid, unloving, worthless, and impossible to please. Unlike the narcissistic parent, children of NPD parents feel they are to blame for any mistakes and are overly willing to accept responsibility. Rappoport (2005) suggested that the negative impacts of being raised by an NPD parent can lead children to lose a clear self-identity and prevent them from fully living their lives. Additionally, there is a high likelihood that children of NPD parents will develop NPD themselves; these children may behave like their parents in an attempt to relate to them (Berg-Nielsen & Wichstrom, 2012). Children of NPD parents may constantly strive to fulfill their parent’s unrealistic expectations and are controlled by their NPD parent even when they become adults themselves (Brown, 2008). On the other hand, some children of an NPD parent may rebel and distance themselves from their parent and grow up disagreeing with others, acting defiant (Brown, 2008). Children of NPD parents may also grow to rely on self-confidence and being approved and thought highly of by others, which aligns with their parent’s NPD behaviors (Brown, 2008). When treating children of NPD parents, one of the initial tasks the therapist is faced with is gaining trust from the child and allowing the child to see that the therapist is not narcissistic; children of NPD parents tend to think that everyone is a narcissist like their parents (Rappoport, 2005). It is important for the therapist to show empathy, kindness, warmth, and positive regard to children of NPD parents because these behaviors contradict those of the NPD parent. A  large component of therapy involves showing

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the child that they do have intrinsic value and helping the child see their selfworth; it is critical that the child understands that their value does not change based on the thoughts of others or their accomplishments. Rappoport (2005) suggests that co-narcissistic people, for instance a child of an NPD parent, are more likely to seek treatment than the primary narcissist and are fortunately easier to help. Couple Case Conceptualization In general, diagnostic techniques can be used as instruments to describe the needs of the client; this is followed by case conceptualization, which focuses on understanding the needs of the client (Sperry, 2005). An effective case conceptualization should link the client’s issue to an appropriate treatment plan and outline the methods for tailoring the treatment plan specifically to the needs of the client. Research suggests that the Five-Factor Model (FFM) of personality can assist with conceptualizing NPD, because of the strong positive correlation between NPD and the FFM concept of extraversion and a strong negative correlation between NPD and agreeableness (Pincus  & Lukowitsky, 2010). Essentially, case conceptualization can help to integrate research and theory into clinical practice (Sperry, 2005). Assessment Recommendations As with many disorders, it is important to consider the range of functioning and phenotypic presentation of a client with traits of NPD (Ronningstam, 2011). For instance, individuals with moderate NPD may not be as callous or egotistical as individuals with severe NPD. Assessment of NPD may also include consideration of whether the presenting problems are temporary or triggered by specific situations. In sum, there is a spectrum of NPD, and it is necessary to assess where a client falls on this spectrum (Ronningstam, 2011), which can have meaningful implications for couples counseling. There are three major subtypes of NPD. The first subtype refers to the overt, grandiose subtype (Caligor et  al., 2015; Russ, Shedler, Bradley,  & Wester, 2008). This type is known for seeking attention, being thick-skinned, exhibiting entitlement and arrogance, and being charming. It is unlike the grandiose subtype to show anxiety or care about the needs of others; it is common for this subtype to exploit others. Notably, the grandiosity displayed by this subtype is primary, meaning it does not stem from defensive or compensatory tactics. The second subtype of NPD refers to the covert, vulnerable, and fragile subtype (Caligor et al., 2015; Russ et al., 2008). This subtype is known for being thin-skinned and exhibiting distress and anxiety. This subtype includes shyness and secret grandiosity. Importantly, grandiose and self-worth is inflated among individuals that fit these subtypes; the key difference is how grandiosity is displayed (Caligor et al., 2015). The fragile subtype likely has alternating cognitive representation of the self (Russ et al., 2008).

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The third subtype is known as the high functioning exhibitionist (Russ et al., 2008). This subtype is known for seeking attention, being competitive, grandiose, and sexually provocative (Russ et al., 2008). Individuals of the third subtype also have various psychological strengths, including being articulate, energetic, and achievement oriented (Russ et al., 2008). Pincus and Lukowitsky (2010) noted that there are various diagnostic, semi-structured interviews to assess NPD, including the Structured Interview for DSM-IV Personality; (SIDP-IV; Pfohl, Blum, & Zimmerman, 1997); the SCID-II (First, Spitzer, Gibbon, & Williams, 1995); the International Personality Disorder Examination (IPDE; Loranger, 1999); the Personality Disorder Interview-IV (PDI-IV; Widiger, Mangine, Corbitt, Ellis, & Thomas, 1995); and the Diagnostic Interview for Personality Disorders (DIPD; Zanarini, Frankenburg, Chauncey, & Gunderson, 1987). Additionally, there are various self-report assessments for NPD, including the Millon Clinical Multiaxial Inventory (MCMI-III; Millon, Davis, & Millon, 1997); the Wisconsin Personality Disorders Inventory (WISPI-IV; Klein et al., 1993); the Assessment of DSM-IV Personality Disorders (ADP-IV; Schotte  & De Doncker, 1996); the Minnesota Multiphasic Personality Inventory (MMPI-2) Personality Disorder Scales (Hicklin  & Widiger, 2000; Somwaru  & Ben-Porath, 1995); the Schedule for Nonadaptive and Adaptive Personality (SNAP) Personality Disorder Scales (Clark, 1993); the OMNI Personality Inventory (OMNI; Loranger, 2001); and the Personality Diagnostic Questionnaire-4 (PDQ-4; Hyler, 1994). The Narcissistic Personality Inventory (NPI) is one of the main measures of severity of NPD (Pincus & Lukowitsky, 2010). Another measure is the Psychodynamic Diagnostic Manual (PDM), which divides NPD into two subtypes: Arrogant/Entitled and Depressed/Depleted. More recently, researchers have found the DSM to focus on levels of grandiosity when diagnosing NPD (Pincus & Lukowitsky, 2010). It is important to note that some narcissistic traits are helpful for generation of positive self-esteem, achievement, and adaptive functioning. This lack of a gold standard for what is normal versus abnormal regarding narcissistic traits can make the disorder challenging to diagnose unless in severe cases (Pincus & Lukowitsky, 2010). Despite the resources for assessment and diagnosis of NPD, Caligor et al. (2015) report that NPD is one of the least studied personality disorders, which makes assessing, diagnosing, and treating individuals with NPD difficult. Another challenge lies in the definition of NPD under the DSM-5. The diagnostic criteria do not align with the core psychological components of NPD, namely feelings of inferiority, emptiness and boredom, affective reality and distress, and vulnerable self-esteem. The wide range of symptom severity of NPD also makes diagnosis challenging (Caligor et al., 2015). In general, there is a continuum of functioning for individuals with NPD. High-functioning individuals with NPD are able to succeed in life but often face set-backs. Middle-functioning individuals

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with NPD are able to function adequately but face significant professional and interpersonal challenges. Low-functioning individuals with NPD are most likely to face challenges as a result of their unstable self-identity and are more likely to have other diagnoses (Caligor et al., 2015). It is also beneficial to assess whether or not the client displays any symptoms of other diagnoses, because research has shown that NDP is comorbid with mood disorders approximately 17% of the time, and of these mood disorders, 12-month bipolar I  disorder was the most prevalent. NPD has been shown to be comorbid with anxiety disorders approximately 15% of the time; Panic Disorder With Agoraphobia was the most prevalent type of anxiety disorder among individuals with NPD. Lastly, NPD has been shown to be comorbid with substance use disorders (particularly drug dependence) approximately 12% of the time (Stinson et al., 2008). Cultural Considerations A client’s culture must be considered during assessment and treatment (Rivas, 2001). Research has suggested that culture plays a more prominent role in personality disorders than any other diagnostic category in the DSM-5. Countries other than the United States, or other cultures, have different norms of what equates to normal versus problematic narcissism. For instance, Asian American women have the lowest prevalence of NPD, and this may be due to their cultural norms of modesty, respect for authority, collectivism, and collaboration. Cultures that are highly individualistic may increase the prevalence of NPD (Rivas, 2001). Additionally, research suggests that the modern U.S. culture has increasingly normalized narcissism, to a degree; this is because it emphasizes selfobsession, high expectations and sense of self, superficial relationships, and little concern for others (Canavan, 2017). This may be partially due to the increase in popularity of online communities and social media (Canavan, 2017). A  study by Zaromb et  al. (2018) found that the top self-absorbed countries were Russia, the United Kingdom, and India; the United States was ranked in the middle, and the least self-absorbed countries were New Zealand, Norway and Switzerland. Treatment Considerations Treatment for NPD is difficult because these individuals will not likely be motivated to change when they have such inflated self-perceptions (Brunell & Campbell, 2011). It is critical to take a holistic approach when treating NDP because of the likelihood that the disorder is comorbid with other disorders (Rivas, 2001). Because of the impacts that a parent’s NPD can have on their partner and their child, individual, couple, and family treatment options need to be considered. Unfortunately, research is lacking regarding the efficacy of therapeutic and psychopharmacology treatments on NPD (Caligor

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et al., 2015). The following section will describe potential treatment options for individuals with NPD, including individual treatment, couples and family treatment, and psychopharmacology. Individual Treatment Pharmacotherapy and Psychosocial Treatments Two main types of treatment for personality disorders include pharmacotherapy and psychosocial treatment (Bateman, Gunderson,  & Mulder, 2015). Pharmacotherapy may be beneficial for individuals with personality disorders such as NPD because problem behaviors may arise due to neurochemical abnormalities. Although research is lacking on pharmacotherapy approaches for NPD, there has been an examination of pharmacotherapy in regard to two similar personality disorders, namely Borderline Personality Disorder and Antisocial Personality Disorder. For these two disorders, previous research has highlighted the use of selective serotonin reuptake inhibitors (SSRIs) and antipsychotic medications. Importantly, pharmacotherapy has not been recommended as the sole treatment approach for Borderline Personality Disorder or Antisocial Personality Disorder, which is likely the case for NPD as well (Bateman et al., 2015). Psychosocial treatments can include behavior therapy, where the focus is on problem solving and psychoeducation, and psychoanalytic treatment (Bateman et  al., 2015). Personality disorders are difficult to diagnose and treat, compared with other disorders, and often are comorbid with other disorders (Callaghan, Summers,  & Weidman, 2003). Psychosocial treatments for NPD tend to be longer-term and aim to address interpersonal processes. Some clinicians have used Functional Analytic Psychotherapy (FAP) when working with NPD (Callaghan et al., 2003). This approach focuses on interpersonal processes to address relationships with others outside of therapy. This approach also uses basic behavioral methods to assist with changing behaviors during therapy; this requires acknowledging and addressing behaviors immediately when they occur during sessions. This approach includes the use of the Functional Idiographic Assessment Template for identifying where a client ranges on five levels of interpersonal functioning. FAP has been shown to help improve NPD behaviors during therapy as well as outside of therapy. For instance, FAP was shown to improve the creation and maintenance of outside relationships; decrease dramatic behavior; and decrease egocentric tendencies (Callaghan et al., 2003). NPD Couples Treatment In couple therapy, it has been suggested that clinicians address splitting, a term used to refer to an unconscious defense mechanism, which refers to

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the narcissist’s tendency to see experiences in a dichotomous way, as really positive or really negative; this can impact couples treatment (Siegel, 2006). A part of splitting for individuals with NPD can include things such as blaming, negative and distorted communication, over-reactivity, and withdrawal after experiencing relational difficulties. It is important to treat the couple from a cognitive, analytic, and psychoeducational approach. When working with a couple where one or both are suffering from NPD, it is critical to help them both better recognize extreme or over-reactive behaviors and thoughts; then, the couple can work to create and maintain less reactive viewpoints. These couples also need assistance learning to express their differences in a neutral way and agree on differences (Siegel, 2006). Individuals with NPD also tend to have unreasonable expectations of others and take advantage of others in an attempt to promote their own advancement, which can therefore hurt relationships (Lachkar, 1998). Using object relations has been shown to be effective when treating couples with NPD by acknowledging the couple’s internal weak spots and conflicts (Lachkar, 1998). When treating couples with NPD, it is critical that the therapist act as a mirror (to help clients identify their behaviors and states) as well as a moderator (to reduce aggression and maintain order). It is also important that couples with NPD learn that their interdependency on one another should strengthen their relationship, not destroy it, as is often the case with NPD because individuals with NPD are drawn to their partner when they enhance their self-esteem but over-reactive and withdrawn when their partner does not (Lachkar, 1998). Carlson and Sperry (2013) discussed the importance of addressing narcissistic rage (often used by the NPD patient to restore their self-esteem as a defense mechanism) in couples treatment for NPD patients. Failing to address narcissistic rage can increase shame, guilt, and depression; the couple needs to feel safe and protected within their therapeutic environment. This can be addressed by the therapist by directly confronting the NPD patient so they that they are aware they are being hostile towards their partner whom they care about; it will be difficult for the NPD patient to maintain their own status of being noble and loving if they know they are seen as hostile and confrontational. This can be done by acknowledging new expectations and ways for the couple to adapt. The NPD couple will naturally engage in defensive, aggressive, and unhealthy conversations and actions during therapy, and it is critical that the therapist acts to neutralize the experiences of couple therapy, which can be a very long process (Carlson & Sperry, 2013). Case Example: Jane and Patrick Jane was a middle-aged woman with NPD. She and her husband, Patrick, came to couple therapy for help with issues impacting their relationship.

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They were a highly attractive, upper middle-class African American couple. During the first few sessions, Jane frequently demonstrated all of the narcissistic characteristics, in that she lacked empathy, struggled with relating to others, and always had a sense of grandiosity with very arrogant behaviors. By her account, she had a well-adjusted childhood where her parents “simply adored her” because she was, by comparison to her siblings, “exceptional at most things.” Jane reported being the “apple of her parents’ eye” and stated that she was “excellent at meeting their appropriately high expectations of me.” Patrick came from a middle-class family with three brothers, where he was in the middle. He reported an unremarkable childhood but stated that he had to get most of his social and emotional needs outside the home because he was “often lost among his siblings.” Patrick stated, “I am used to fading into the background.” Jane is a highly successful attorney and Patrick is an accountant. The couple have two adolescent children. Jane tended to blame all relationship issues on Patrick and all of the relationships that preceded him. Patrick is her third husband. Jane’s other two marriages happened when she was young and did not last more than a year each. She would show up to sessions in designer clothes and compare herself to celebrities with the same clothes. Patrick came from a middle-class childhood where there were occasional financial struggles. He often seemed as though he was in awe of this woman, and he was in disbelief that someone like her who, in his words, was “so put together and beautiful” would even consider dating him, while she idealized the opportunity to be viewed as one of the most powerful couples in the Chicago-area Black community. Whereas Jane was dressed in designer clothes, Patrick often noted that he shopped at consignment stores when shopping for himself or his children just so that Jane could maintain the lifestyle she desired. He was clearly the more involved parent as she often forgot appointments for lessons, play dates with others, etc. Patrick regularly volunteered free accounting services for a local non-profit organization. Jane liked his success in supporting the organization and the community status that came with it, but was indifferent about the impactful work and the cause that her husband had championed. The therapist soon discovered that while Jane had achieved moderate success, she often embellished the truth about things. She could not just be a successful lawyer; she was next in line for “partner.” She was eventually fired from the very firm where she would likely be making “partner.” She presented herself as a socialite with major “connections” to celebrities, when she was only marginally associated due to a celebrity’s desire to support her husband’s work with appearances at his events. Patrick was clearly in love with the “idea” of her and struggling with his own issues of insecurity and self-doubt; however, Jane often used session time to berate him for the role that he played in her “occasional” missed appointments with her children or any other shortcoming.

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Diagnostic Criteria Jane presented with all the typical characteristics of NPD, including grandiosity and arrogance. She had an inflated sense of self-worth and was very egotistical. She had a history of unstable relationships and was on her third husband in 20 years, whom she often exploited and blamed. Jane felt that others admired her and acted as if she had attained a status not experienced by most; she demonstrated cognitive distortions more consistent with adolescents, like the tendency to blame others or minimize her behavioral shortcomings. Her behaviors had impacted her professional life, her personal and romantic life, and her family life. Patrick reported struggling with issues of anxiety and depression, exacerbated by Jane’s harsh criticisms and emotional neglect of his needs in the relationship. Assessment Considerations Initial assessment was a crucial component of working with this couple. Part of this assessment included identifying the severity and frequency of NPD characteristics for Jane and depression and anxiety symptoms for Patrick. It was very clear that the Jane’s problems were not temporary or recent; she had struggled with them for years, and her problems were becoming increasingly negative, whereas Patrick’s depressive history seemed to begin when he and Jane had children. Jane was also evaluated for additional mental health issues before treating her NPD. The couple agreed that Jane’s anger and Patrick’s withdrawal after her anger responses were the critical dynamic in their relationship that caused significant issues between them. Therefore, the focus in treatment began with assessment and cognitive preparation where the therapist and clients spent time identifying the anger patterns (triggers, etc.) in their own words, the function that anger served for them, and an introduction to the underlying principle of REBT, being that their underlying beliefs about the world, others, and themselves is what causes the low frustration tolerance and subsequent struggles with anger. Patrick’ tendency to emotionally withdrawal after Jane’s angry responses towards him was also analyzed and the couple was asked to deconstruct this dynamic as it was occurring at home. Case Conceptualization Case conceptualization was used to better understand the needs of this client. The therapist examined Jane and Patrick’s background and history. Then, the therapist reviewed their presenting problems and how Jane’s NPD and Patrick’s depression and anxiety impacted their relationship. Next, the therapist outlined the treatment plan for the couple, which would include addressing Jane’s most destructive NPD symptoms and Patrick’s underlying (and

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somewhat unconscious) anger and resentment towards Jane. The therapist conceptualized this couple’s struggles and issues as a function of cognitive distortions. Treatment Considerations Effective treatments for NPD remain elusive, depending on the severity of the disorder; however, Rational Emotive Behavioral Treatment (REBT) has found some limited success in helping the NPD member of the couple explore his/her thought processes and the impact these have on the dynamics of the relationship. Much of the early work with this couple utilized a pragmatic approach that was aimed at getting them “therapy ready” in a non-threatening way. Jane attended individual therapy sessions as well as couple therapy with Patrick. It was apparent during initial individual and couples sessions that she did not respond well to criticism, and even though the sessions were becoming increasingly ineffective in the clinician’s estimation, she always ended them by stating how successful she believed them to be. After all, why would she even agree to therapy if she did not believe that she could be successful at it? During couples sessions, Jane completely missed social cues demonstrating poor empathy when it came to issues that were of importance to her husband. For instance, she often antagonized Patrick during sessions when he was clearly expressing anger about something or was really flippant when he disclosed something from his work with children and families that saddened him. During therapy, both Jane and Patrick stated that the “real issue” was the anger that had begun to erode their relationship. They were both initially overtly resistant to the idea of her narcissistic behaviors and his enabling behaviors’ role in maintaining their current struggles. However, there was a clear concern about the impact of their anger on their relationship with one another and their children. So, the path to least resistance with this couple was to employ an REBT-based couple therapy approach; this emphasized the work of Albert Ellis, which posits that it is not the things that happen to us in our lives that lead to struggles (i.e., anger) but rather our view of those things that disturb us. Although working with the couple’s distorted belief system about themselves and their relationship was often difficult, the couple recognized how their collective anger with one another had begun to erode their relationship, so there was some agreement on the focus of couple treatment. Hence, if the couple’s view of themselves and the things that were taking place within their relationship changed, then they could change the outcomes and consequences. Thus, the therapist began to focus on the types of thinking that led to these struggles, which include but are not limited to: 1. Inferential distortions, mind reading, and emotional reasoning that lead people to misinterpret what is happening around them.

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2. Discomfort intolerance about unwanted events that result in anxiety and frustration in an attempt to ward off perceived threats to well-being or one’s self-image. 3. Expectations of the self, the world, and others that are held as demands (this refers to the idea that one’s circumstances must be a certain way, leading to low frustration tolerance). Next, the clinician and couple began to explore and assess for other causal factors in an effort to help them understand where their respective learning may have come from. A lot of the work was a non-threatening psychoeducational approach at this point, introducing them to various causes of anger, including cognitive, physiological, and behavioral components. The therapist utilized case studies for the couple, allowing them to apply the principles in a non-threatening way with the intention of drawing parallels at a later date to their current struggles. A lot of the work involved an introduction to Ellis’ Rational Emotional Behavioral Therapy Model, where the connection between activating events–belief systems–consequences are explored, with the eventual objective being the disputing of the irrational beliefs that maintain undesired consequences. This approach allowed the couple to apply their understanding to actual experiences they had had with one another. A part of this phase of the process was dedicated to cognitive change, where they engaged in self-analysis, actively challenging demands directed at one another, others, and the world. The aim was to develop an increased level of frustration tolerance and an ability to fully accept themselves, one another, the world, etc. They were able in the short term to develop empathic abilities through the use of apology letters and even role reversal, ultimately developing a more task-oriented attitude towards dealing with problems. Jane struggled with expressing meaningful empathy, but Patrick appeared willing to accept some of her superficial efforts. For a short period, they both seem to embrace this very pragmatic approach, with both seeming to enjoy a sense of mastery and achievement when “successful” at application of the concepts. The next part of the process was to help at a physiological level to develop strategies for reducing tension through relaxation, anxiety management, and maintaining a sense of humor. A skills acquisition component was aimed at using their anger more adaptively rather than destructively, ultimately engaging in problem-solving behavior (i.e., assertiveness training, problem-solving training, interpersonal effectiveness). Afterwards, there was work focused on the development of a hierarchy of situations that they were likely to encounter as a couple, exposing them via imagery and ultimately through real-life situations, while exploring their potential responses. There was some moderate progress, which was interrupted with an abrupt termination by the wife at the very end of counseling. The therapist found this pragmatic approach

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to be the least threatening to this couple and fairly easily understood and applied. However, the therapist saw the skills-building REBT-based component as only the prep work for the eventual work in more challenging areas. Clinical Outcome The challenge in the treatment of this couple was addressing the couple as a dyad so that the wife did not become the sole focus. While this couple was difficult to treat, any semblance of success hinged on the cultivation of Jane’s empathy for Patrick’s perspective, experiences, and feelings. However, it was also of the utmost importance that Patrick developed increased selfesteem and a greater reliance on his support system outside of his wife. This was critical to later work with the couple, as he had grown fairly dependent upon his wife for validation and would often not get it, which triggered his emotional withdrawal. While work in the area of empathy would be key to the desired clinical outcomes for this couple, there was a substantial amount of time spent on cultivating the “buy-in” from Jane. As those living with Narcissistic Personality Disorder go to great lengths to make good impressions, this wife really took to the pragmatic approach of rational emotional behavioral therapy. The treatment buy-in came as the result of the wife’s desire to demonstrate her capacity as a quick learner. Affirmations of Jane’s efforts appeared to lead to an increased desire for excelling at therapy, which worked to the couple’s advantage. On one hand, Jane seemed to pride herself on learning from the “expert” and doing well in therapy, while Patrick appeared to develop a greater self-esteem and self-efficacy as the result of the feelings of mastery and achievement, elicited by his work with REBT and associated assignments. The change that was taking place could easily be misinterpreted as fairly superficial, given what appears to be extrinsically motivated change. However, as the wife was able to begin seeing cognitive and behavioral change in her husband it reinforced her desire to remain in treatment doing the work that she had “become pretty good at” doing. The buy-in created in the first phase, pragmatic approach of REBT facilitated some observed and selfreported cognitive and behavioral change for the couple, which increased the possibility of more deep and substantive personality level change in the future. Subsequent work focused more on the teaching of empathy and validation skills to both partners in the dyad. The couple began to utilize the skills taught to them during the first phase of treatment, which led to an increased capacity for couples problem solving. With every successful application of the core philosophy of the theory and skills acquired, this appeared to lead to moderate sustainable change. During individual sessions, Jane demonstrated a greater willingness to explore attachment issues and the family system out of which her issues may have been created. Patrick began to explore his own

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identity outside of the marriage as both partners were not just equipped with skills, but also had developed a greater awareness of how their respective behaviors were cultivating a marital system that reinforced the barriers to change. The reality is that the struggles with NPD would continue with less severity, but both had developed a more adaptive response to anger triggering situations and a more empathic connection to each other’s experiences and feelings. Conclusion The DSM-5 characterizes individuals with NDP as individuals with a consistent pattern of attention seeking, over-dramatic behavior, inappropriate sexual behavior, and emotionality (American Psychiatric Association, 2013). Relationships involving individuals with NPD often include a lot of turmoil (Brunell & Campbell, 2011), as individuals with NPD tend to be in love with themselves (Lachkar, 1998) and use others as instruments to maintain their narcissistic esteem (Brunell & Campbell, 2011). Case conceptualization and assessment are critical to understanding a client with NPD’s background, their individual needs, and their symptom severity. NPD may be impacted by culture; for instance, cultures that promote collectivism and collaboration are likely to have a lower prevalence of NPD compared to individualistic cultures (Rivas, 2001). Common treatments for personality disorders such as NPD include psychotherapy (Bateman et al., 2015) and psychosocial treatment (Bateman et al., 2015; Callaghan et al., 2003). Early on in couple treatment, a more structured approach might be beneficial as a way to gain buy in from the couple, especially the NPD partner. Therapy may take place at the individual level, or couples or family level, and even a combination. Future research is needed to clarify the most effective therapies for couples impacted by NPD of one or both partners. References American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5®). Washington, DC: Author. Bateman, A. W., Gunderson, J., & Mulder, R. (2015). Treatment of personality disorder. The Lancet, 385(9969), 735–743. doi:10.1016/S0140-6736(14)61394-5 Berg-Nielsen, T. S.,  & Wichstrom, L. (2012). The mental health of preschoolers in a Norwegian population-based study when their parents have symptoms of borderline, antisocial, and narcissistic personality disorders: At the mercy of unpredictability. Child and Adolescent Psychiatry and Mental Health, 6(9), 19–32. doi:10.1186/1753-2000-6-19. Brown, N. W. (2008). Children of the self-absorbed: A grown-up’s guide to getting over narcissistic parents. Oakland, CA: New Harbinger Publications. Brunell, A. B.,  & Campbell, W. K. (2011). Narcissism and romantic relationships: Understanding the paradox. In W. K. Campbell & J. D. Miller (Eds.), The handbook of narcissism and narcissistic personality disorder: Theoretical approaches,

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empirical findings, and treatments (pp.  344–350). Hoboken, NJ: John Wiley  & Sons. doi:10.1002/9781118093108.ch30 Canavan, B. (2017). Narcissism normalisation: Tourism influences and sustainability implications. Journal of Sustainable Tourism, 25(9), 1322–1337. doi:10.1080/096 69582.2016.1263309 Caligor, E., Levy, K. N., & Yeomans, F. E. (2015). Narcissistic personality disorder: Diagnostic and clinical challenges. American Journal of Psychiatry, 172(5), 415– 422. doi:10.1176/appi.ajp.2014.14060723 Callaghan, G. M., Summers, C. J., & Weidman, M. (2003). The treatment of histrionic and narcissistic personality disorder behaviors: A single-subject demonstration of clinical improvement using functional analytic psychotherapy. Journal of Contemporary Psychotherapy, 33(4), 321–339. doi:10.1023/B:JOCP.0000004502.55597.81 Campbell, W. K., & Campbell, S. M. (2009). On the self-regulatory dynamics created by the peculiar benefits and costs of narcissism: A  contextual reinforcement model and examination of leadership. Self and Identity, 8, 214–232. doi:10.1080/15298860802505129 Carlson, J., & Sperry, L. (2013). The disordered couple. London, England: Routledge. Clark, L. A. (1993). Manual for the schedule for nonadaptive and adaptive personality. Minneapolis, MN: University of Minnesota Press. Dimaggio, G. (2012). Narcissistic personality disorder: Rethinking what we know. Psych Central. Retrieved March  30, 2018, from https://pro.psychcentral.com/ narcissistic-personality-disorder-rethinking-what-we-know/ Ehrenberg, M. F., Hunter, M. A.,  & Elterman, M. F. (1996). Shared parenting agreements after marital separation: The roles of empathy and narcissism. Journal of Consulting and Clinical Psychology, 64(4), 808–818. doi:10.1037/0022006X.64.4.808 First, M. B., Spitzer, R. L., Gibbon, M. W. J. B., & Williams, J. B. (1995). Structured clinical interview for DSM-IV axis I disorders. New York, NY: New York State Psychiatric Institute. Hicklin, J.,  & Widiger, T. A. (2000). Convergent validity of alternative MMPI-2 personality disorder scales. Journal of Personality Assessment, 75(3), 502–518. doi:10.1207/S15327752JPA7503_10 Hyler, S. E. (1994). Personality diagnostic questionnaire-4. New York, NY: New York State Psychiatric Institute. Klein, M. H., Benjamin, L. S., Rosenfeld, R., Treece, C., Husted, J., & Greist, J. H. (1993). The Wisconsin personality disorders inventory: Development, reliability, and validity. Journal of Personality Disorders, 7(4), 285–303. doi:10.1521/ pedi.1993.7.4.285. Lachkar, J. (1998). Narcissistic/borderline couples: A  psychodynamic approach to conjoint treatment. In J. Carlson  & L. Sperry (Eds.), The disordered couple (pp. 259–284). Bristol, PA: Brunner/Mazel. Links, P. S., & Stockwell, M. (2002). The role of couple therapy in the treatment of narcissistic personality disorder. American Journal of Psychotherapy, 56(4), 522– 538. doi:10.1176/appi.psychotherapy.2002.56.4.522 Loranger, A. W. (1999). IPDE: International personality disorder examination: DSMIV and ICD-10 interviews. New York, NY: PARS Psychological Assessment Resources. Loranger, A. W. (2001). OMNI personality inventories: Professional manual: OMNI personality inventory OMNI-IV personality disorder inventory. New York, NY: Psychological Assessment Resources.

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Millon, T., Davis, R. D.,  & Millon, C. (1997). MCMI-III manual. Piscataway, NJ: National Computer Systems. Pincus, A. L., & Lukowitsky, M. R. (2010). Pathological narcissism and narcissistic personality disorder. Annual Review of Clinical Psychology, 6, 421–446. doi:10.1146/ annurev.clinpsy.121208.131215 Pfohl, B., Blum, N., & Zimmerman, M. (1997). Structured interview for DSM-IV personality: Sidp-IV. Washington, DC: American Psychiatric Association. Rappoport, A. (2005). Co-narcissism: How we adapt to narcissism. The Therapist, 1, 1–8. doi:10.1.1.559.4503 Rivas, L. A. (2001). Controversial issues in the diagnosis of narcissistic personality disorder: A review of the literature. Journal of Mental Health Counseling, 23(1). Retrieved from http://amhcajournal.org/ Ronningstam, E. (2011). Narcissistic personality disorder in DSM-V–in support of retaining a significant diagnosis. Journal of Personality Disorders, 25(2), 248–259. doi:10.1521/pedi.2011.25.2.248 Russ, E., Shedler, J., Bradley, R., & Western, D. (2008). Refining the construct of narcissistic personality disorder: Diagnostic criteria and subtypes. American Journal of Psychiatry, 165, 1473–1481. doi:10.1176/appi.ajp.2008.07030376 Schotte, C.,  & De Doncker, D. (1996). ADP-IV questionnaire: Manual and norms. Edegem, Belgium: University Hospital Antwerpen. Siegel, J. P. (2006). Dyadic splitting in partner relational disorders. Journal of Family Psychology, 20(3), 418–422. doi:10.1037/0893-3200.20.3.418 Somwaru, D. P., & Ben-Porath, Y. S. (1995, March). Development and reliability of MMPI-2 based personality disorder scales. In 30th annual workshop and symposium on recent developments in use of the MMPI-2 and MMPI-A, St. Petersburg Beach, FL. Sperry, L. (2005). Case conceptualizations: The missing link between theory and practice. The Family Journal, 13(1), 71–76. doi:10.1177/1066480704270104 Stinson, F. S., Dawson, D. A., Goldstein, R. B., Chou, S. P., Huang, B., Smith, S. M., . . . Grant, B. F. (2008). Prevalence, correlates, disability, and comorbidity of DSMIV narcissistic personality disorder: Results from the wave 2 national epidemiologic survey on alcohol and related conditions. The Journal of Clinical Psychiatry, 69(7), 1033–1045. Retrieved from https://www.ascpp.org/resources/psychiatryresource/journal-of-clinical-psychiatry/ Widiger, T. A., Mangine, S., Corbitt, E. M., Ellis, C. G., & Thomas, G. V. (1995). Personality Disorder Interview–IV. Odessa, FL: Psychological Assessment Resources. Zanarini, M. C., Frankenburg, F. R., Chauncey, D. L., & Gunderson, J. G. (1987). The diagnostic Interview for Personality Disorders: Interrater and test-retest reliability. Comprehensive Psychiatry, 28(6), 467–480. doi:10.1016/0010-440X(87)90012-5 Zaromb, F. M., Liu, J. H., Páez, D., Hanke, K., Putnam, A. L.,  & Roediger, H. L. (2018). We made history: Citizens of 35 countries overestimate their nation’s role in world history. Journal of Applied Research in Memory and Cognition, 7(4), 521– 528. doi:10.1016/j.jarmac.2018.05.006

10 THE HISTRIONIC–OBSESSIVE COUPLE Len Sperry and Michael P. Maniacci

T

here was a time when relational conflict between an obsessional husband and a histrionic wife was the most common presentation in couple therapy (Martin & Bird, 1959). Then, a preponderance of obsessive husbands and histrionic wives—represented by a couple dubbed the “love sick wife and cold sick husband”—was reported, yet data also showed a sizeable number of marriages with histrionic husbands and obsessive wives, which were called “in-search-of-a mother” marriages (Martin, 1981). In other words, either partner can manifest the obsessive or histrionic style. Nevertheless, the central conflicts are the same: intimacy, power, and boundaries (Doherty, Colangelo, Green,  & Hoffman, 1985). Although today the borderlinenarcissistic couple may be overrepresented in couple therapy, the histrionic– obsessive couple is nevertheless still seen with regularity in clinical practice. This couple is the focus of this chapter. It describes a dynamic–systemic view of the histrionic–obsessive couple that emphasizes personality and relational dynamics involved in conflict and its resolution in couple therapy. It begins with an overview of theory and research on this couple. Then, it reviews DSM-5 characterizations of both the Histrionic Personality Disorder and the obsessive–compulsive personality disorders. Next, it describes the case conceptualization of this couple. Following that are assessment, treatment, and cultural considerations. A case example illustrates these considerations. Finally, a concluding note summarizes recommendations for working with this couple. Overview: Theory and Research on the Histrionic–Obsessive Couples

Early descriptions of the histrionic–obsessive couple emphasized personality structure and dynamics rather than systemic factors (Sperry, 2004). Thus,

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the histrionic—then called “hysterical”—partner was typically profiled as the only girl, only child, or youngest child in a family constellation in which her mother was cold, masochistic, and resentful of being a mother and woman, so much so that she overindulged her daughter as compensation for not being able to love and nurture her. Her father was described as charming, indulgent, and seductive at times, while controlling and rejecting at other times. The end result was that the histrionic girl-in-training came to believe that her father loved her more than he loved his wife. Thus, she learned to get her own way by playing each parent against the other by being coy, seductive, pretending she was ill, or having temper tantrums. Adulthood for the histrionic female became a search for a strong, idealized father–husband who would take care of her (Goldberg, 1975; Martin  & Bird, 1959). Later descriptions tend to emphasize both psychodynamics and systemic factors (Bergner, 1977). From this integrative dynamic–systemic perspective, relational conflict is viewed as a function of both personality structure and interactional patterns. To date, relatively little research has been reported on couples with histrionic and obsessive styles and disorders, although many clinicians and theorists remain convinced that their relational pattern is common. Martin (1981) found that in 300 couples studied, the majority of male partners exhibited the obsessive–compulsive style, whereas the female partners exhibited the histrionic style. He also reports data on 200 other marriage relationships in which the male partners exhibited a histrionic style and the female partners showed the obsessive style. Goldberg (1975) reported on 200 physicians and their wives treated in couple therapy. He found that the majority of physicians exhibited the obsessive–compulsive style while their wives exhibited the histrionic style. Our view is that the personality styles of histrionic and obsessive partners are best understood as persistent, characteristic patterns of behavior that originate within the individual’s family of origin. As such, these personality patterns are the result of both temperamental and characterological influences, including genetics, family constellation, modeling, reinforcement, and the creative adoption of basic lifestyle convictions or schemas (Sperry, 2016b). It is noteworthy that because the historic–obsessive relational patterns are complementary and reciprocal, if the couple get divorced, they are likely to be attracted over and over to someone similar to their former partner. The next subsection begins with typical manner in which the histrionic– obsessive couple establish a relationship—mate selection—and how this relationship becomes maladaptive and symptomatic. Although we have noted that either sex can be histrionic or obsessive, for convenience we will follow the convention of indicating the histrionic partner as “she” and the obsessive partner as “he” throughout this chapter. The remainder of the section focuses on the unique relational conflicts of this couple.

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The Process and Dynamics of Mate Selection At the outset of a marriage between a histrionic individual and her partner, neither feels like a whole, competent individual. Instead, each believes himself or herself to be unable to participate in life in significant ways. Thus, in the process of mate selection, each partner engages in what might be termed a search for his or her own missing “puzzle pieces” in the individual of the other (Sperry, 1978). In other words, whereas healthier individuals base their selection of a life partner heavily on such factors as mutual liking and shared interests, goals, and world outlook, the histrionic individual and her prospective partner characteristically underemphasize such factors and place a disproportionate emphasis on finding a mate who seems able to function in life in ways in which they personally feel incomplete and inadequate. Basically, both individuals perceive the potential mate as “their other half.” Unfortunately, that half is one they have cut off in themselves, so they are essentially attracted to that which they have rejected or are negatively inclined, neither of which are in their consciousness. Nevertheless, they proceed to “fall in love.” It is as if each had a “private pact” (Sperry, 1978) that says, in effect, “Alone I can’t make it in life, but if I can find someone who makes up for my deficiencies, perhaps together we can function as one whole, competent individual.” This pact likely reflects childhood attachment problems, which are a hallmark of personality disorders. In adult relationships, individuals with personality disorders may act out early abuse, neglect, violence, and other forms of childhood attachment failure. Irrespective of causes, the ingrained personality disorder pattern forms early. For example, when a child experiences terror within the first 18 months of life, the left hemisphere of the brain—the rational language part of the brain—has not developed sufficiently and cannot realistically process such events, so the right hemisphere either puts up a shield of denial or comes to believe that the self is somehow flawed or inadequate (Solomon & Tatkin, 2011). Histrionic Partner The histrionic partner conducts a search for the ideal mate with a number of expectations. Perceiving herself to be fundamentally weak, helpless, and incapable of adequately conducting her own affairs, she searches for an ideal caretaker who can help her navigate the stressful vicissitudes of life. More precisely, the histrionic individual experiences herself as someone with a tendency to be swept away by the emotional currents of reality at the expense of clear, logical thinking and coping behavior. Not surprisingly, she places a premium on finding an individual who can maintain a considerable degree of calm and objectivity, appraise situations clearly and logically, and determine a reasonable course of action (Bergner, 1977). However, this search is doomed from the start. Besides her perceived weakness, she lives in fear of being overwhelmed by a truly assertive and competent male. Accordingly,

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she selects a male who will neither pressure her nor threaten her tentative sense of personal autonomy, but who will pamper and protect her (Dreikurs, 1946). The histrionic individual’s requirements for a partner then assume a contradictory quality of wanting him to be strong and help her deal with life, but not to exhibit those qualities when dealing with her. In her ultimate selection of a partner, it initially appears that she has succeeded in her quest. Obsessive Partner The obsessive partner, for his part, also engages in a search for his missing “puzzle pieces.” Logical, avoidant, and detached in his everyday demeanor, he experiences life as drab and colorless and so finds that the heightened emotionality and vivaciousness of the histrionic individual adds needed spice to his life. Because he tends to be out of touch with his feelings and desires and locked into a stultifying daily routine, he finds the histrionic individual’s flair for life and spiritedness refreshing. Before meeting her, he never believed he measured up to the cultural stereotype of the real man. But in his relationship with her, he suddenly and unequivocally feels like a real man. In the face of her apparent weakness and helplessness, he takes on the role of the strong, steady guardian who finds the rational solution. In their relationship, he finds this role enormously rewarding (Bergner, 1977). Couple and family theorists have long sought to explain how it is that two individuals who are so strongly attracted to each other come to a point when they can no longer tolerate each other. Dreikurs (1946) was one of the first to observe that the qualities that initially attract two people to each other are basically the same factors that cause discord and divorce. He noted that any human quality or trait can be perceived in a positive or a negative way. An individual can be considered either kind or weak, or strong or domineering, depending on one’s point of view. Dreikurs suggested that one individual does not like another for his or her virtues, nor dislike that individual for his or her faults. Rather, an emphasis on an individual’s positive qualities grows out of affection for that individual, just as an emphasis on weaknesses grows out of rejection. This emphasis on the individual’s weakness or negative trait provides an excuse for having to communicate, to negotiate, and to resolve conflicts. In other words, talking about problems is just about the only time they do talk. When asked what attracted her to her partner, what made him different from others, the histrionic individual often mentions physical attraction. But upon further probing she may admit, “I like his gentleness and stability . . . the way he could get things done, how he could plan things out . . . how well he uses money.” Looking at her background, we might discover that she experienced much instability in her upbringing, that she had difficulty making plans and commitments, that she had trouble budgeting and using money and time wisely. These traits reflect her histrionic style and some of the specific need fulfillment she seeks.

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In responding to the same question, the obsessive individual often gives the culturally expected response, “Physical attractiveness.” Then he may add, “I  like her free spirit; she really knows how to have a good time.  .  .  . She’s the kind of individual who doesn’t get bogged down in things. . . . She can be the life of the party . . . and she’s a very generous and giving person.” An investigation into his background and personality style may suggest how his unfulfilled needs could be complemented in relationship with such an individual. Each of these individuals actually has qualities that the other craves and values, and thus they are attracted to each other. Everything goes along smoothly until one or both are threatened, at which point courage begins to wane. When cooperation and courage decrease, defensiveness increases and the attracting qualities come to be perceived in a much more negative way. Whereas she previously viewed her partner as gentle and stable, now she describes him as weak and cowering. Whereas previously she perceived him as being able to plan and structure things, now she sees him as domineering and inflexible. Initially, he saw her as free-spirited, but now he views her as flighty, coquettish, and scatterbrained. Rather than generous and giving, she is now deemed a careless spendthrift. As courage wanes, so does trust. The more two partners become defensive, the more they are likely to disown any responsibility for a problem and blame each other. This is the basis of most couples’ conflicts (Sperry, 1978). The next section further describes relational conflicts from the perspectives of the histrionic and the obsessive partners. Relational Conflicts in Histrionic–Obsessive Couples The histrionic individual soon comes to recognize some of the costs of her partner’s refusal to take authentic personal stands. She does things that she realizes he finds provocative and objectionable. Yet, seldom does he protest or react emotionally. Rather than voicing any strong personal wants or desires, he insists that “anything is fine” with him. In time, this predictable response leads the histrionic individual to draw a number of conclusions. She comes to view her partner as indecisive, ineffectual, and emasculated. She thinks that he must be angry or have some objections to her behavior, but because he says nothing, she concludes that he must be dishonest and untrustworthy in his dealings with her. And she wonders whether his failure to show anger means he no longer cares for her. She feels increasingly unloved, emotionally abandoned, and unable to make intimate contact with her husband. Furthermore, she experiences an increasing sense of rage. The realization that her obsessive partner can respond to her need only superficially is devastating for her. Although her partner displays an endless willingness to listen to her troubles, to provide reassurance, and to present logical solutions to her difficulties, he offers little else. Consequently, she feels overburdened and overwhelmed. This state of affairs provides even

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more reason for the histrionic partner to experience an increasing sense of abandonment and rage as the months and years go by. In her anger and her desire to gain revenge, she resorts to predictable behaviors. Initially, she verbally attacks her partner. Rather than being informative and, thus, potentially constructive, these attacks are often marked by scathing, global indictments of her husband’s character. She assaults him simultaneously on numerous fronts. Next, she becomes provocative: she overspends, has affairs with other men, or resorts to hypochondriac preoccupations. And when her partner seems substantially unmoved by all of these behaviors, she may pull out her ultimate weapon: the suicidal gesture. All too frequently she is left with the painful notion that her husband is really a “nice guy” who deserves better, that she is the helpless victim of overpowering and irrational emotions and actions, and that she is doomed by external forces to be a “crazy bitch” (Bergner, 1977). Like his partner, the obsessive individual at first believes he has made the ideal mate choice. He has chosen a woman who makes him feel like a man without requiring him to be authentic and assertive—both of which he finds so difficult. Nevertheless, the enormous emotional consequences of this choice soon become increasingly evident. He begins to realize that he is being exploited, that their relationship is a one-way street in which his partner does all the taking and he all the giving. Her wants and desires always seem to take priority in the relationship. Furthermore, he has great difficulty in expressing the growing anger he feels toward his partner or taking a stand against her behavior. On those rare occasions when he is forthright, his assertiveness is met with dire consequences. Predictably, she becomes rageful. Ultimately, the husband concludes that it is not worth fighting or taking a stand. Instead, he settles into other ways of expressing his anger and preserving his sense of autonomy. Typically, he employs passive-aggressive tactics learned in his family of origin. He withdraws more and more from his partner, often into his job, citing as his justification the requirements of the job and the increasing expenses of the family. He makes ever greater use of the tactic of “stonewalling” (Gottman, 1994) or emotional detachment. Finally, he gets even by abdicating his relational responsibilities outside those of breadwinner, resulting in his partner’s becoming overburdened with responsibilities and enormously harried in her attempts to fulfill them. As the relationship progressively deteriorates and his partner engages in ever more extreme behavior, the obsessive individual becomes ever angrier. He becomes furious at her seemingly unprovoked verbal attacks, her overspending, her affairs, her hypochondriasis, and her suicidal threats and gestures. At the height of the relational crisis, he feels thoroughly exploited. Even more devastating is the mounting conviction that he is neither loved nor respected and is kept around only because of his paycheck and because she is afraid to leave (Bergner, 1977).

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The Histrionic–Obsessive Couple in Therapy When they present for couple therapy, both partners are firmly entrenched in their maladaptive ways of relating and behaving. Unfortunately for the histrionic individual, the usual provocations are no longer eliciting the expected response from his or her partner, leading to escalating behaviors (somaticism, affairs, other impulsive acts) that further compound a residual feeling of being “not good enough.” This feeling in turn exacerbates the histrionic individual’s fear of abandonment, resulting in even more dramatic attempts to capture attention. Over time, as the behaviors and provocations grow tiresome to the partner, the obsessive–compulsive partner starts to feel exploited. Since the obsessive–compulsive partner has difficulty expressing emotions, especially those that are negative, he or she will express anger in passive-aggressive ways (withdrawing, becoming more of a “workaholic”), which only serve to further inflame his or her histrionic partner’s insecurity (Landucci & Foley, 2014, p. 34) Predictably, the result is that the incensed histrionic partner escalates and complicates matters by more extreme emotional displays or acting-out behaviors, and the maladaptive cyclical pattern is repeated. Initially, resistance in couple therapy reflects the fantasy of both partners that the therapist will somehow “fix” the other. Instead, the therapist’s role is to assist both partners to understand and accept responsibility for their part in the dysfunction as a whole without assigning blame to the other. Once this “fixing” fantasy is dispelled, the therapist can help the couple relinquish their maladaptive pattern by assisting them in setting collaborative goals (Landucci & Foley, 2014). DSM-5 and the Histrionic–Obsessive Couple Couples with a histrionic–obsessive pattern who engage in couple therapy present with either one or both meeting DSM-5 criteria for a personality disorder, or they exhibit histrionic or obsessive traits or style. In either circumstance, awareness of DSM-5 criteria is essential in establishing not only a prognosis, but also the type and duration of treatment. When one or both partners are diagnosed with personality disorders, treatment often requires couple therapy to address systemic dynamics as well as individual psychotherapy to address individual dynamics (Haight,  & Benoit, 2017). Sperry (2004) presents a detailed case study of the treatment of a couple in which the wife met the criteria for Histrionic Personality Disorder and the husband for obsessive–compulsive personality disorder. Combined individual and couple therapy were utilized over an extended period. Such extended and intensive combined treatment is the rule rather than the exception with such couples. On the other hand, couples who have histrionic and obsessive personality styles tend to be more amenable to a single treatment modality: couple therapy, usually of a shorter duration. The presence of comorbid

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conditions such as anxiety, depressive, or substance use disorders may complicate treatment. Here is a DSM-5 characterization of both the Histrionic Personality Disorder and obsessive–compulsive personality disorder, respectively (American Psychiatric Association, 2013). DSM-5 and the Histrionic Personality Disorder Individuals with this personality disorder are characterized by an unremitting pattern of attention seeking and emotionality. They tend to be uncomfortable in situations where they cannot be the center of attention. They may engage in provocative and inappropriate seductive sexual behavior. Their emotional reactions tend to be shallow and rapidly shifting. Typically, they draw attention to themselves with the way they dress. Their manner of speech tends to be impressionistic with few details. They are likely to perceive relationships as more intimate than they really are. They can be dramatic and overly exaggerate their emotional expressions. Furthermore, these individuals are easily influenced by others or circumstances (American Psychiatric Association, 2013). DSM-5 and the Obsessive–Compulsive Personality Disorder Individuals with this personality disorder are characterized by an unremitting pattern of perfectionism, orderliness, and control instead of flexibility, openness, and efficiency. They are overly preoccupied with details, rules, and schedules. Their perfectionism interferes with completing tasks due to their overly strict standards. They are overly devoted to work and productivity, to the exclusion of leisure activities and friendships. When it comes to matters of values, morality, or ethics, these individuals are inflexible, scrupulous, and overly conscientious. Often, they are unable to discard worn-out or worthless objects that have no sentimental value. They will not delegate tasks or work with others unless it can be on their terms. Not surprisingly, these individuals are also rigid and stubborn. Finally, they are misers with money, and it is hoarded in the event of future catastrophes (American Psychiatric Association, 2013). Our clinical observation is that attractions are common between individuals diagnosed with DSM-5 Cluster B personality disorders (antisocial, borderline, histrionic, and narcissistic) and Cluster C personality disorders (avoidant, dependent, and obsessive–compulsive). Specifically, we’ve observed that individuals in Cluster B or C tend to be attracted to an individual with a polar opposite personality. Consistent with the mate selection literature, these individuals look to others for the qualities they lack and assume that a relationship with that individual will make them feel more complete or whole. Quite commonly, the histrionic is attracted to the obsessive individual because of the histrionic’s need for order and stability, while the obsessive individual is fascinated by the histrionic’s free-spirited attitude.

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This is not to say that mate attraction only occurs when both partners have diagnosable personality disorders. In fact, if only one partner meets criteria for the diagnosis of a personality disorder, the other partner often shows personality traits in the opposite direction. In our clinical experience, we can recall a number of women with Histrionic Personality Disorder who were attracted to and married men with the obsessive–compulsive style, meaning that they met some but not all of the criteria for the personality disorder. Assessment Considerations An adequate assessment of the histrionic–obsessive couple involves an evaluation of both individual dynamics and systemic or relational dynamics. Individual dynamics would include the personality styles or disorders of each partner, and relevant developmental and social history. The evaluation of the systemic dynamics would include the stage of the relationship, related boundary, power, and intimacy issues, relational skills, family-of-origin issues, relational satisfaction, and commitment to and expectations for the couple relationship. Each partner’s personality shapes the relationship, just as the relationship shapes that partner. Thus, it is essential to know about specific personality dynamics, personal and family history, and past treatment. Sometimes a personality disorder may already be under control, as when the depressed obsessing partner is taking medication, seeing a therapist, and doing better. Sometimes they are not, and that partner blames the other for his reactions (Taibbi, 2017). Accordingly, a comprehensive assessment is essential. The use of self-rating scales and personality inventories may be part of this assessment. The routine use of a self-rating measure of relational functioning, like the Dyadic Adjustment Scale or the Marital Satisfaction Inventory-Revised, is common in couples work, particularly with disordered couples. Unique among standardized personality inventories is the Millon Clinical Multiaxial Inventory (MCMI-IV) with its focus on personality styles and disorders. This inventory can be “extremely useful in arriving at hypotheses about the personality structure and interactive pattern of the underlying immediate conflicts, overt anxiety, and depressive, or acting-out, features that partners present within couples therapy” (Nurse & Sperry, 2012, p. 61). It not only helps differentiates personality style from disorder; the computergenerated report can also be quite helpful in suggesting treatment strategies and options. MCMI0-IV is the only standardized personality inventory that experienced clinicians we know routinely use with couples in therapy. Case Conceptualizations: Individual and Couple Essentially, a case conceptualization is a way of summarizing diverse information in a brief, coherent manner for the purpose of better understanding

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and explaining an individual’s or couple’s presenting concerns, and a strategy for guiding the treatment process (Sperry, 2015). Based on the assessment of both individual and couples’ dynamics, the clinician can develop case conceptualizations for both partners and the couple relationship. Individual Case Conceptualization The purpose of the individual case conceptualization is to provide a reasonable explanation for the individual’s presenting problem in light of their personality dynamics, relevant developmental, and social and health history, and for developing a treatment plan that is tailored to their needs, culturally sensitive, and effective. Central to developing a clinically useful individual case conceptualization is the identification of the individual’s underlying maladaptive pattern. For the histrionic individual, this pattern is typically a variant of: get attention from others but pay a high price or be compromised. For the obsessive individual, this pattern is typically a variant of: be overconscientious while being emotionally distant from others. Couple Case Conceptualization The purpose of the couple case conceptualization is to provide a reasonable explanation for the couple’s conflicts, distress, and concerns, and to develop a treatment plan that is effective and culturally sensitive. Like a family case conceptualization, it is a systemic case conceptualization based on a detailed assessment of systemic dynamics (Sperry, 2016a). These include couple, parental, and sibling subsystem dynamics, capacity for negotiation, power sharing, intimacy, the couple’s resources and strengths, and their couples narrative. It should also integrate both systemic dynamics and individual dynamics of each partner. For example, the couple’s conflict might be explained as an attempt to sustain a relationship when the obsessive partner is greatly stressed and emotionally unavailable to the histrionic partners. It should also specify an intervention strategy based on this conceptualization. Generally, this intervention strategy involves both a systemic strategy of rebalancing the couple subsystem, and an individual strategy of modifying individual dynamics of each partners (Sperry, 2004). A primary goal of culturally sensitive couple therapy is “to develop an understanding of specific ways in which clients view the world (and their corresponding values and beliefs)” (Hardy  & Laszloff, 2002, p.  578). This translates to identifying their respective worldviews and their composite worldview. Specifying worldviews is a key component of this case conceptualization. What follows is a brief characterization of the worldviews of individuals with histrionic and obsessive personalities. Essentially, the worldview of the histrionic individual is that life is unpredictable, controlling, and demanding, but that she is nevertheless entitled to love and special care and consideration. Her self-view is that she is deserving

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of love and attention, and she needs others to love and admire her in order to be happy (Sperry, 2016b). Furthermore, she views others favorably only as long as she can elicit their attention and affection. She uses deception, charm, flirtation, and manipulation to achieve and then reduce the unpredictability of life, especially regarding loss of love and attention. Finally, she believes that despite her incessant craving for love, real love is never possible. Despite her notorious craving for love, the histrionic individual believes that her behavior is the result of coercion and thus cannot believe that real love is possible. The worldview of the obsessive individual is that life is demanding and unpredictable, and thus it is important to be in control, right, and proper. His view of self is that he must be reliable, competent, and righteous to cover for his deficits and shortcomings. Deep down, he believes he is flawed and unlovable. Furthermore, he believes he must take responsibility for others, as well as for things that go wrong (Sperry, 2016b). These convictions lead him to work untiringly to achieve and be perfect. Accordingly, he fears failure, acts tentatively and indirectly, and takes few, if any, risks, especially interpersonal risks. Because of his fear of being overrun and losing control, he uses passive-aggressive behavior in an effort to prevent this from happening. The upshot is that he does not attempt appropriate, direct, and fair assertive measures and, further, remains markedly unmoved by his partner’s attempts at controlling him. Again, a change in this conception of self in a more constructive direction is fundamental to a change in his assertive behavior and his willingness to be influenced by his partner. Cultural Considerations Culture is a broad concept comprising several interrelated dimensions, including: race, ethnicity, gender, religion, age, social class, and sexual orientation. Since it is unlikely that both partners share the exact same cultural profile, it might be said that couple therapy can be conceptualized as a cross-cultural experience (Hardy & Laszloff, 2002). This experience can be captured in a cultural formulation. A cultural formulation is an integrative statement that explains and incorporates all relevant cultural factors that influence the presenting problems of both partners. More specifically, it describes each partner’s cultural identity and level of acculturation. It also provides a cultural explanation, called an Explanatory Model, of their relational presentation, as well as the impact of cultural factors on their respective personalities and levels of functioning (Sperry, 2015). In addition, it describes cultural elements that may impact the relationship between the couple and the therapist, and whether cultural or culturally sensitive interventions are indicated. When acculturation level is high, cultural dynamics tend to have relatively little impact on the presenting problem, whereas personality dynamics tend

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have more impact. However, when acculturation level is low, cultural dynamics tend to have a significant impact. There are times when both personality and cultural dynamics will have a similar impact. This happens in cultures wherein females are expected to be dependent on and subordinate to males, and at the same time, a female partner also exhibits a pronounced dependent personality style and sometimes a histrionic style. The importance of determining the mix of cultural and personality dynamics is critical in determining if and when culturally sensitive treatment is indicated (Sperry, 2015). Unfortunately, relatively little research has been published on cultural factors impacting this couple. Nevertheless, there are cultural stereotypes commonly associated with the histrionic and obsessive–compulsive personalities. These include the characterizations that the histrionic personality is a flirtatious, bubble-headed female, and that the obsessive personality is a humor-less, overly rigid male. In Western culture, the female partner is stereotypically regarded as more emotional and males are stereotypically regarded as more controlled (Sperry, 2004). Although the Histrionic Personality Disorder may be diagnosed more frequently in females in clinical settings, the reality is that “sex ratio is not significantly different from the sex-ration of females within the respective clinical setting. In contrast, some studies using structured assessment report similar prevalence rates among males and females” (American Psychiatric Association, 2013, p. 668). In contrast, the obsessive–compulsive personality disorder appears to be diagnosed twice as often among men (American Psychiatric Association, 2013). Nevertheless, certain obsessive traits, such as being hard working, punctual, and attentive to detail, are noted just as often among professional women as among professional men. This suggests that changing gender roles account for women becoming increasingly empowered and displaying the kind of behaviors and traits associated with workplace success. This change may also be a reason for the apparent decline of the histrionic–obsessive pattern in couple therapy today (Sperry, 2004). Treatment Considerations A basic premise of effective treatment for a couple in which one or both present with significant psychopathology, particularly if both meet DSM criteria for personality disorders, is that both systemic couple therapy and individual psychotherapy are almost always indicated. In other words, in such situations, conventional couple therapy, wherein both partners are only involved in conjoint treatment, is not likely to be effective. Such a dual-focused therapy involves a treatment process with three phases for effectively treating the histrionic–obsessive couple. The phases are: (1) establishing a working therapeutic alliance; (2) rebalancing the couple relationship; and (3) modifying individual dynamics in the partners. Sometimes an additional phase of skill training may be necessary. If so, skill

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training interventions are utilized concurrently with or following the second phase. 1.  Engagement and the Therapeutic Alliance The first phase of treatment involves engaging the couple by establishing and maintaining a productive therapeutic alliance. A couple’s initial contact with the therapist frequently occurs during a period of extreme emotionality and behavior and of severe marital maladjustment. Such couples can be helped to a state of greater calm, order, and optimism about their relationship. It is particularly valuable for the couple and the therapist to share certain assumptions. The first is that neither partner is “crazy” or “mentally ill,” but rather that each is an individual whose behavior makes sense and who is responsible for this behavior. The second is that neither partner is “the problem,” but rather that each is in therapy in the role of client, because the behavior of each contributes to the shared marital difficulties (Bergner, 1977). The third is that each partner’s family-of-origin pattern can powerfully influence the couple’s relationship. These assumptions short-circuit some destructive and distressing conceptions typically held by the histrionic–obsessive couple at the outset of the treatment. Initially, the couple believe that the histrionic partner is insane, because of this individual’s extreme behavior and emotionality in the apparent absence of any adequate reasons. The therapist’s treatment of the histrionic partner as an individual whose behavior has rational antecedents, who is responsible for her behavior, and who is sane has a multiple impact. First, it reduces the distressing fear that the other partner will abandon her. Second, it deprives her of an excuse for being irresponsible. Third, it deprives him of an excuse for not confronting her about her behavior. Similarly, each partner believes that he or she alone is completely at fault for the relationship’s problems. This phenomenon, most easily observed in the histrionic partner, accounts for vacillations, in each of the couple, between rage at the partner and severe self-condemnation. A  consistent stance on the part of the therapist, in which he or she repeatedly insists, demonstrates, and acts in accord with the view that each partner is contributing to the marital difficulties, provides each with a more livable, realistic general view and, in the bargain, a better basis for responsible self-scrutiny and action. The achievement of such a therapeutic alliance usually results in a rapid and dramatic diminution of intense emotionality and extreme behavior. The end result is that the couple become amenable to viewing themselves and their relationship in a calmer and more orderly fashion. Furthermore, discussion of how family-of-origin patterns develop and impact the relationship can be quite useful in calming the couple by helping them to understand the specific learned patterns they have acquired. Understanding such factors, which are often beyond each partner’s conscious

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awareness, helps them to realize how much their relational problem is not of their own making, although they can still take responsibility for it. 2.  Restoring Balance to the Couple Relationship After a working relationship between the couple and therapist is achieved, the second phase of treatment consists of establishing or restoring balance in the couple’s relationship. Rebalancing is typically needed in the areas of boundaries, power, and intimacy (Doherty et al., 1985) and represents the main systemic focus of change in couple therapy with histrionic–obsessive partners. Structural family techniques as well as strategic family therapy methods and techniques have been quite effective in accomplishing this rebalancing of boundaries and power. Issues of rebalancing the relationship of intimacy can be effectively addressed with communication or family-oforigin approaches. Accomplishing such rebalancing can be quite challenging. In fact, it may represent the therapist’s most difficult challenge in working with the disordered couple. In effecting such change, the “system will struggle to maintain equilibrium, even if that equilibrium includes the maintenance of unhealthy interaction patterns” (Haight & Benoit, 2017, p. 478). 3.  Modifying Individual Partner Dynamics The third phase of treatment involves modification of personality features in the individual partners. This phase often occasions psychodynamic change in couple therapy. The primary individual goals for both the histrionic person and her partner are relatively similar, though their starting points differ. There are two goals: first, that each of them comes to adopt more direct, honest, and fair modes of influence and assertion; and, second, that each comes to both cooperate and communicate honestly in the face of the other partner’s efforts to control. As previously noted, both the histrionic and the obsessive partners are often dishonest in their attempts to control each other. She misrepresents facts, dishonestly seduces, and exaggerates her feelings, while he pretends he has no personal needs or desires, or that he is not bothered by her behavior. In addition, she pretends utter helplessness, feigns illness, threatens suicide, and finds other unfair means of exerting enormous pressure on him. He, for his part, resorts to passive-aggressive tactics such as physical and emotional withdrawal, avoidance of feelings, procrastination, and indecisiveness. Through all of this, both partners remain remarkably uninfluenced by the rather extreme means taken by the other. By their actions, each is saying to the other that he or she will not be controlled. The goal of getting each partner to abandon such tactics and to employ more honest, forthright, and fair measures in relating to each other is central

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in the treatment of this relationship. This goal may be pursued therapeutically in any number of different ways. An Adlerian or Cognitive Therapy treatment strategy that deals with these problems simultaneously and modifies the mistaken lifestyle conviction or maladaptive schemes can be particularly valuable. Case Example: Frank and Karen Frank and Karen had been married for close to 20 years when couple therapy began. Karen, a high school teacher of Mexican American descent, had been in long-term treatment with a therapist for chronic, recurrent bouts of depression from which she seemed to achieve only temporary relief. Psychotropic medications proved relatively ineffective and were discontinued. She still reported intense periods of dysphoria, fleeting thoughts of suicide, and chronic dissatisfaction with her life. Her individual therapist provided supportive psychotherapy for her and claimed that “adjustment” to her “condition” was the best she could attain. Well into her second year of supportive therapy, she began reporting that her husband’s health had become an issue. After he had seen numerous physicians, the consensus of opinion was that he was experiencing “stress-related” disorders and should consider some form of counseling himself. Karen’s psychotherapist referred him to one of the authors. Frank was in his late 40s when he arrived at the office. He and Karen had one son in his mid-20s, who had recently been graduated from a well-known university with an advanced degree and had moved back home with his parents. The son’s educational career had been paid for by his parents. Frank was a large man, mildly overweight and balding, with a noticeable skin rash about his forehead. He had a bachelor’s degree from a local college, worked as a consultant for a large firm, and reported that in his duties as a logistics consultant he flew more than 80,000 miles per year. He came in claiming that he was not sure he needed any counseling. His physicians had “sent” him because of two problems that they seemed unable to “fix.” The skin rash, although considerably better than in past years, was still “bad,” and caused him some irritation. More pressing was his insomnia. When he traveled and stayed in hotels, he had trouble sleeping, barely getting more than two or three hours of sleep per night. Because he was often on the road more than four nights a week, this was becoming a serious issue for him. Despite having trouble sleeping, he never missed a meeting or failed to report to work. He thought that if he kept this up, he would be “in a lot of trouble,” and that sooner or later such a pace would catch up to him and more seriously affect his health. In addition, he reported a third, “unrelated” problem. He described what initially sounded like a fear of heights. Flying was often a nightmare for him. Crossing bridges, taking escalators, or riding in glass elevators were usually,

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but not always, anxiety provoking. Given his considerable travel schedule, this could be problematic, particularly when he anticipated a stressful business meeting or appointment. Otherwise, he felt confident he could manage anxiety, but he kept some “tranquilizers” prescribed by his physician in his pocket “just in case.” Although he rarely used them, he had that reassurance. Frank was reluctant to talk much about himself. While he was an excellent, methodical reporter of the various details of his life, he seemed to lack any sense of himself as the individual to whom the assorted irritations and frustrations of life had happened. In other words, he talked about what happened to him, but rarely did he seemed to be present in any of his discussions. He was polite, even cordial, but not friendly in the usual manner; instead, he gave the impression of a man discussing with his mechanic the latest glitches in his car. “It” simply was not functioning up to speed. Assessment Considerations The assessment included comprehensive clinical interviews with each partner and a conjoint assessment of couple dynamics. The MCMI-IV was completed by both Karen and Frank. What follows are some relevant developmental and social history for each. Karen Karen was the youngest born of four siblings, the prized little girl in a closeknit family. She was especially cute and received considerable attention for her brightness and vivaciousness. Shortly after her third birthday, her mother became ill with what was called—Karen believed—“some kind of involutional melancholia.” Mother’s illness was very difficult for the family. Her father picked up much of the slack, worked two jobs, and withdrew much of his attention from Karen. While she was still the favorite grandchild of her grandparents, she secretly envied her mother’s new, privileged position. Her mother gained considerable sympathy and seemed to be excused from much of the burdens of the household. Everyone regularly worked around her, and a common family motto was, “Don’t upset your mother!” Karen’s bouts of depression appeared during adolescence, after the failure of a “love” with an older, college-bound boy. He “left” her to go away to a major university, and she felt devastated, and she claimed to have never fully gotten over the “blow.” She eventually decided to go into teaching, where she specialized in drama. Her earliest memory was of her third birthday. She was sitting at the table with everyone looking at her. She felt special, loved, and amazed by all the gifts and the huge cake placed before her. Her next memory was of her first day of school, at age 5. She remembers walking into class, feeling pretty in her new dress. The teacher, a woman, told her to take a seat near the back of the room—her name was at the “back” of the alphabet—and Karen felt offended.

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She believed the teacher did not like her. Her first reaction was to look at the teacher—and then at herself, for maybe she was not dressed “nice enough” to be up front. She felt sad. Frank Frank was the oldest of two and the only boy. His father was a violent alcoholic with unpredictable mood swings. His mother was a long-suffering woman, who used Frank as her sole support. His sister was born blind, and Frank remembers the frequent threats to send her “away” to an orphanage should she be too much of a bother. He took on as his mission to keep her out of the orphanage and became her surrogate parent, teacher, and friend. He kept her from such a fate almost single-handedly. Frank worked from the time he was 14. His first job was on a loading dock, allowing him to see much of life’s seamier side at too young an age. He vowed to make life better for himself, to never lose his temper or drink or become a “drunk” like his father. He eventually got his GED, went to college—which he paid for himself—and worked his way up through various jobs, eventually into management and then consulting with others about how to run their businesses. His earliest memory was the following. He was five years old, and he walked out onto the fire escape of the family apartment. As he was looking around, admiring the view, he heard a scream. His mother came rushing out, grabbed him, and swept him back into the apartment. She yelled at him and told him how dangerous it was to be on the fire escape, warned him to be more careful, and scolded him. He felt confused, but vowed to be more careful and not upset her. DSM-5 Not surprisingly, upon interview, Frank met DSM-5 criteria for the obsessive– compulsive personality disorder, and his anxiety symptoms were coded as an Unspecified Anxiety Disorder rather Specific Phobia to account for his concern about heights. Similarly, Karen met DSM-5 criteria for the Histrionic Personality Disorder as well as for unspecified depressive disorder. Results of the MCMIIV disclosed the same personality disorders were consistent with the interview diagnoses. Case Conceptualizations: Individual and Couple Individual Case Conceptualization Karen’s dysphoria and chronic dissatisfaction with her life can be understood in light of her displacement as the center of attention in her family of origin and then later in her marriage as her son and husband became increasingly

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emotionally unavailable. Her maladaptive pattern was identified as continually seeking attention even though it was withheld or taken from her. Frank’s insomnia, fear of heights, somatic symptoms, and his hard-paced work life can be understood in light of early life demands on him to care for his sister and family, his feeling avoidance, and using somatic symptoms as a reprieve from unreasonable demands. His maladaptive pattern was identified as being overly conscientious, blameless, and emotional distant from others. Couple Case Conceptualization The following interlocking dynamics were explained to the couple. Karen grew up feeling special but cheated. Although she was aware that she could get attention for her specialness, she was also aware of how fleeting it could be. Getting attention was wonderful, but being able to hold onto it was another matter. She measured life and others as to how they could take care of her, notice her, and she became a master at playing roles to attract their attention. As she grew older, she felt her “specialness”—her beauty, youth, and energy—fading. When her son (a planned only child, so that he would always feel special) left home, the empty-nest syndrome hit her hard. She felt abandoned by her husband, who worked too many hours, soon to be abandoned by her son (he too had left her for college some five years earlier, as her first love had, and might eventually move out and go on his own), and lonely and pessimistic. The onset of her current, chronic depression roughly coincided with her son’s leaving for college. She was using depression as a coping device to deal with life, to draw others to her as she had seen modeled by her mother. She was probably genetically loaded for depression, and she learned to use it in such a way as to rally support for herself. Frank grew up believing it was “all on him.” In many ways he was right— his conscientiousness helped keep his family intact. He played the role of the “parentified child” in his family. Gradually, the line between conscientiousness and control began to blur. Unless he controlled his own life and that of others, he sensed a somewhat uneasy, impending doom. His solution was to do more, to work harder, to control more, and to be busier. His only break from such a rigid, tense style was to be “ill.” By being afraid of heights and unable to sleep, he could ask for a break or perhaps seek to take some time for himself without having to admit that he was shirking responsibility. His rash was his way of saying, “This is irritating me. It’s getting under my skin.” The interlocking dynamics gradually became clear to the couple. Karen’s depression was reframed as a way of asking to be cared for and her “moodiness” as her trying to keep the relationship together. She valued love and the marriage, and she wanted her family to be happy. She was trying to keep them together and to look out for her husband and his health. Frank was

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trying to keep his family together, too, and the motive for his working so hard was reframed as being the same motive Karen had. In effect, they were told that their symptoms were serving the same purpose, just in different ways. The basic therapeutic question was now clear: could they now communicate such desires in more prosocial, constructive ways? Frank’s controlling and Karen’s emotionality were complementary. She was encouraged to “teach” him to be more passionate, and he was urged to be her consultant on matters of organization. They grasped this way of working, and though they still had characteristic “rough spots,” they found that they grew more affectionate with each other. Karen’s depression lifted and she found more satisfaction with Frank, even though she could still be somewhat “blue.” He was encouraged to go into business for himself and, after some hesitancy, he did. He began to work out of his home, and his consulting business flourished. He gained greater control over his schedule, worked fewer hours more efficiently, and found more pleasure at home. A brief course of cognitive–behavior therapy for his phobic issues—with his wife as “coach” and “co-therapist”—worked very well. Within a short time, he found himself crossing bridges, riding escalators, and flying with virtually no anxiety. Cultural Considerations Frank identified as a middle-class Caucasian male. He was highly acculturated and his presenting concerns were primarily personality-based. His worldview was that life was dangerous and relentlessly demanding for him to be highly productive and make no mistakes. His explanatory model for his presenting concerns was that job stress, Karen’s demands, and bad health caused his symptoms. Karen identified as a third-generation, middle-class Mexican American female. She was moderately acculturated and her presenting concerns were also primarily personality-based. Her world-view is that life is unpredictable, controlling, and demanding, but she is entitled to love and special care and consideration. Her explanatory model for her presenting concerns was that others withheld caring and concern and that a chemical brain imbalance caused her depression. The explanatory models for both partners confirmed for the therapist that personality dynamics rather than cultural dynamics underlie their presenting problems. Even though Karen was from an underrepresented minority, it was concluded that no culturally sensitive treatment or interventions were indicated then. Treatment Considerations A two-pronged approach was recommended. First, individual therapy was suggested in order to help Frank understand the nature of his problems. Second, couple therapy was recommended. Frank had reported numerous

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stresses and strains in his marriage. His wife was “moody, unpredictable” and given to outbursts that frustrated him. At one time during the initial interview, he hesitatingly admitted that he secretly looked forward to his trips away from home in order to get some peace. If he could not sleep on the road and he found no peace at home, he feared he might lose his mind. His coming to this admission was the most nearly emotional moment in the entire interview. Frank was told that by working on the relationship, he could perhaps get some “relief ” at home and on the road. Such an approach, he was told, would be the most “efficient” way of working. He liked that concept and agreed to it. He would be seen twice a month individually and, with Karen, as a couple twice a month. Engagement and the Therapeutic Alliance The couple was seen conjointly for the first session. The therapist began by explaining to the couple that neither of them was “sick” and that each was simply expressing in his or her characteristic style what neither had “permission” or “ability” to say with his or her mouth. Both were interested in such an approach. Frank was fascinated by the concept that communication could occur beyond an individual’s control. He knew it happened, he had seen it at work many times, but he had never thought any such process would be going on in him without his knowing. Karen was amused by his comment and pointed out that if he “knew” he was doing such things, he would not be able to do them. She beamed at the therapist, as if waiting for a reward or praise. Karen was an attractive woman who seemed constantly tense and strained. She wore too much makeup, forced smiles that frequently seemed mildly insincere, gesticulated with her hands, and made facial expressions that seemed exaggerated within the context of whatever was being discussed. She gave the impression of a little girl playing the part of a grown-up, as if she had gotten into her mother’s clothes and makeup and was playing dress up for an admiring but unseen audience. The concept was that neither was “crazy,” but rather their communication style was problematic. Not only did the receiving partner not understand the communication, but the sending partner was not completely aware of the message. Accordingly, their first therapeutic task would require that they first accept responsibility for sending the message—that is, acknowledge that a message was being sent—and then to clarify, in clearly consensual terms, what the message was. Once this was accomplished, the next task involved their willingness to act in such a way as to respond favorably to the message being sent. Rebalancing the Couple Relationship Rebalancing the relationship typically includes conflicts with power, intimacy, and boundaries (Doherty et al., 1985). Needless to say, this rebalancing

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process was challenging. Power was fairly well distributed: Frank was “distant,” didactic, in charge, until Karen became upset, emotional, “hysterical,” and had a “fit.” She typically got her way at that point. Frank would calm the situation by arranging things the way she wanted, and in the process, he would take charge, organize, and structure the necessary changes and, therefore, be in power again. Karen would allow this until she felt he cared more about his “damn schedule” than he did about her; then she would grow impatient, become upset, and the cycle would be repeated. In a strangely satisfying way, such a cycle worked for them. This very cycle, which in session became known as their “map,” was pointed out to them. Frank readily grasped it and examined it in all its ramifications. Karen had a harder time comprehending the pattern. The therapist realized that two processes were at work: first, although the verbal-analytic presentation suited Frank’s style well, it did not meet Karen’s more global-imagistic processing; and, second, the very cycle that the couple engaged in at home was repeating in session. Frank, in best parental mode, began teaching and lecturing Karen, and she, in childlike manner, “tried” to follow but “couldn’t.” Graph paper was taken out, and the map was drawn up with colored pens, detailing the very transactions that were taking place, including those occurring in session. Karen readily grasped the relational transaction pattern once it was graphically represented by the map, and she wanted to post copies of it all over their house. Boundaries and intimacy were not as easily addressed. A  triangle existed, with their son vacillating between being a husband-surrogate for his mother when Frank was on the road and acting like a “buddy” and loyal student-child to his father when Frank was home. His presence both kept the marriage going in its current style and perpetuated the very problems that, without his presence, might lead to some kind of resolution. The next several weeks of couples treatment struggled with these issues. On the one hand, although it was tempting to involve their son in the sessions and switch to family therapy, this became problematic for the clinician. To bring him into a couple therapy format would perpetuate the very issue he was helping to maintain, that is, his intruding on the couple’s relationship. It was decided not to include him, and work began to strengthen the couple’s bonds without their son in the sessions. A ritual was established: after every session, the couple was to go out on a date. This helped. In addition, the map was expanded (both verbally and pictorially) to show how their son fit within the pattern and how he could be removed. To Frank, it was presented that his son needed to “stand on his own” and that Frank needed to expand his own social network. For Karen, the suggestion was framed in such a way to show that by encouraging her son to “separate,” she would be strengthening not only her marriage, but her son’s

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future as well. She agreed, but the weaning process was difficult for all of them. Eventually, their son was removed from the map. Individual Therapy Frank was already being seen individually twice a month by the couple therapist, and Karen was being seen weekly by her individual therapist. Communication between the therapists became crucial. Although skeptical at first, Karen’s therapist agreed to engage her in more exploratory treatment. The following dynamics slowly emerged for each of them. Clinical Outcome Near the end of their first conjoint session, when asked if either partner had a question or concern, Frank leaned forward and in a very serious tone, asked the therapist: “Can our relationship be fixed?” The therapist responded with: “You both seem to want it and that is very encouraging.” Treatment involved working with their individual and systemic dynamics in individual and couple therapy. The road was rocky at times, but the clinical outcome was positive. After a year and a half, the couple progressed to the point of monthly maintenance sessions. At this point, Karen continued to sees her individual therapist for supportive work. Frank occasionally “checks in” for an individual session, mostly to make sure he does not “overdo it.” Each reports considerably more satisfaction with the marriage and little, if any, conflict. Frank has learned to be less rigidly controlling, and Karen, although still somewhat “dramatic,” feels more connected and valued. Having her husband work out of the home and spend more time with her, she reports, has helped her tremendously. Conclusion The case of Karen and Frank illustrates the key diagnostic, assessment, case conceptualizations, cultural, and treatment considerations involved in working effectively with the obsessive–compulsive couple. It also highlights some key recommendations for working with this couple. The most important of these is that when both partners present for couple therapy with significant psychopathology, particularly if both meet DSM criteria for personality disorders, providing only systemic couple therapy is seldom effective. Instead, a focused, combined approach consisting of individual and conjoint sessions is the treatment of choice. Effective use of individual sessions involves focusing on the interlocking personality disorder dynamics that impact the relationship. Then couples sessions can focus on rebalancing the relationship while decreasing skill deficits and increasing functional capacity. Such an approach not only is consistent with research on effective couple therapy but is also what such couples most need to live successfully together.

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References American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author. Bergner, R. (1977). The marital system of the hysterical individual. Family Process, 16, 85–95. Doherty, W., Colangelo, N., Green, A., & Hoffman, G. (1985). Emphasis of the major family therapy models: A  family FIRO analysis. Journal of Marital and Family Therapy, 11, 299–303. Dreikurs, R. (1946). The challenge of marriage. New York, NY: Hawthorn. Goldberg, M. (1975). Conjoint therapy of male physicians and their wives. Psychiatric Opinion, 12(4), 19–23. Gottman, J. (1994). Why marriages succeed or fail. New York, NY: Simon & Shuster. Haight, M.,  & Benoit, E. (2017). Personality disorders and systems. In J. Russo, J. Coker, & J. King (Eds.), DSM-5 and family systems (pp. 473–499). New York, NY: Springer. Hardy, K., & Laszloff, T. A. (2002). Couple therapy using a multicultural perspective. In A. Gurman & N. Jacobson (Eds.), Clinical handbook of couple therapy (3rd ed., pp. 569–559). New York, NY: Guilford Press. Landucci, J.,  & Foley, G. (2014). Couples therapy: Treating selected personalitydisordered couples within a dynamic therapy framework. Innovations in Clinical Neuroscience, 11(3–4), 29–36. Martin, P. (1981). Defining normal values in marriage. International Journal of Family Psychiatry, 2, 105–114. Martin, P., & Bird, H. (1959). The “love-sick” wife and the “cold-sick” husband. Psychiatry, 22, 242–246. Nurse, R., & Sperry, L. (2012). Standardized assessment. In L. Sperry (Ed.), Family assessment: Contemporary and cutting-edge strategies (2nd ed., pp. 53–82). New York, NY: Routledge. Solomon, M., & Tatkin, S. (2011). Love and war in intimate relationships: Connection, disconnection, and mutual regulation in couple therapy. New York, NY: W. W. Norton & Company. Sperry, L. (1978). The together experience: Getting, growing and staying together in marriage. San Diego, CA: Beta Books. Sperry, L. (2004). Family therapy with a historic–obsessive couple. In M. Macfarlane (Ed.), Family treatment of personality disorders: Advances in clinical practice (pp. 149–172). Binghamton, NY: Haworth. Sperry, L. (2015). Diagnosis, case conceptualization, culture, and treatment. In L. Sperry, J. Carlson, J. Duba-Sauerheber, & J. Sperry (Eds.). Psychopathology and psychotherapy: DSM-5 diagnosis, case conceptualization and treatment (3rd ed., pp. 1–14). New York, NY: Routledge. Sperry, L. (2016a). Teaching the competency of family case conceptualizations. The Family Journal: Counseling and Therapy with Couples and Families, 24, 279–282. Sperry, L. (2016b). Handbook of diagnosis and treatment of DSM-5 personality disorders (3rd ed.). New York, NY: Routledge. Taibbi, R. (2017). Doing couple therapy: Craft and creativity in work with intimate partners. New York, NY: Guilford Press.

11 THE EATING DISORDERED COUPLE Sofie Azmy

E

ating Disorders (EDs) are prevalently represented across myriad racial/ethnic, sexual and gender orientation, and generations. They can be difficult to treat, and though recovery is possible, rates remain low. Only 46% of clients with Anorexia Nervosa (AN) and two-thirds of clients with Bulimia Nervosa (BN) achieve full recovery (Linville & Oleksak, 2013). Unfortunately, EDs have significantly high weighted mortality rates (i.e., deaths/1000 person years), ranging from 1.93 in BN to 5.86 in AN. Partnered women tend to suffer from more severe symptomology than their non-partnered counterparts (Zak-Hunter  & Johnson, 2015). AN has one of the highest mortality rates of any mental disorder, and adults with persistent AN suffer with a chronic, debilitating, treatment-resistant condition (Thompson-Brenner, 2016). Due to the high mortality, associated costs of treatment, and relatively low recovery rates, effective treatments are in high demand. Unfortunately, much of the research on couples with EDs focuses on heterosexual couples where the ED partner is female. There is a paucity of research on same-sex ED couples and heterosexual couples where the ED partner is male. This chapter overwhelmingly reflects this unfortunate bias in the literature. Notably, partners of individuals struggling with EDs have been described as a critical factor in the individual’s life either by enabling and maintaining the disorder or by aiding in recovery (Bulik, Baucom, Kirby, & Pisetsky, 2011). Fischer, Baucom, Kirby, and Bulik (2015) have examined how specific supportive partner behaviors (e.g., acceptance and validation) may enhance ED recovery (Fischer et al., 2015). Thus, committed romantic relationships not only provide a distinct context for ED symptom manifestation, but also

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provide an environment that may facilitate recovery (Zak-Hunter & Johnson, 2015). Zak-Hunter and Johnson (2015) report common relationship problems when one partner suffers from an ED, including emotional intimacy issues, problematic sexual functioning, and relationship conflicts. Effects of Eating Disorders on Couples High percentages of individuals struggling with eating disorders are in committed partnerships, and partner dynamics can either have a positive or a negative impact on treatment and recovery (Bulik et  al., 2011). Evidence suggests that eating disorder symptoms and relationship dynamics reciprocally influence one another (Linville, Cobb, Shen,  & Stadelman, 2016). Linville and colleagues (2016) suggested a theoretical model indicating that as participants felt more stable in their relationship, both their eating disorder symptoms and the impact of the eating disorder on the relationship decreased. Similarly, as participants felt less stable in their relationship, both their eating disorder symptoms and the impact of the eating disorder on the relationship increased. Research studies found that EDs impact and are impacted by couple communication, sexual functioning, relational boundaries, and emotional health (Dick, Renes, Morotti, & Strange, 2013). Struggles to resolve conflict and a sense of secrecy surrounding the Eating Disorder are two common deficiencies in the patterns of communication experienced by ED couples (Dick et al., 2013). Adults with Bulimia Nervosa (BN) generally lack constructive communication skills and tend to be impulsive, which increases negative interactions within their relationships (Kirby, Runfola, Fischer, Baucom, & Bulik, 2015). The presence of the Eating Disorder itself creates an additional number of potential topics for conflict (e.g., conflict over eating patterns). Additionally, partner comments about weight and body shape were shown to have a negative influence on female partners’ relationship satisfaction, as well as their beliefs about their bodies and levels of body satisfaction (Linville et al., 2016). Sexual intimacy is another area of a couple’s relationship that an Eating Disorder may affect. Studies have shown that women with EDs report lower libido, may have increased feelings of hatred toward their bodies, and experience feelings of shame and unworthiness (Dick et al., 2013). A key feature of Eating Disorders is body shame and distress, which likely contribute to a patient’s anxiety around exposing his/her body to partners and engaging in sexually intimate acts. Hormonal changes influenced by EDs also decreased libido and interest in sex, which can be damaging to the couple (Kirby et al., 2015). Not surprisingly, partners of women with EDs have reported overall dissatisfaction with their sexual relationships (Huke & Slade, 2006). Couples affected by an Eating Disorder may struggle with several negative emotions. Women with Eating Disorders are likely to display avoidant

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behaviors and experience feelings of anxiety and fear of rejection regarding their intimate relationships. They may also have trouble trusting others and feel isolated (Dick et al., 2013). The disorder may serve a protective function against fear of failing or rejection and feelings of inferiority and decrease the likelihood of engaging in or maintaining an emotionally intimate relationship, which may inhibit the individual from engaging in an intimate relationship (Dick et al., 2013). Individuals with Binge Eating Disorder (BED) experience emotions intensely and have been described as having difficulties with boundary setting and over-involvement in relationships, making intimate relationships stressful (Kirby et  al., 2015). Partners may feel helpless and unable to cope with the problem of the Eating Disorder. There may also be a tendency to take on the emotional responsibility for the Eating Disorder while struggling with their own sense of isolation—all of which has a negative impact on the relationship (Dick et al., 2013). Attachment Patterns and Relational Dynamics in Eating Disorders Eating Disorders can serve as a way to cope with painful emotions or limit emotional expression and connection; therefore, individuals may attempt to get their attachment needs met through their Eating Disorder (Linville et al., 2016). Therefore, attachment patterns may be another area impacting couple relational issues (Dick et al., 2013). Attachment can be described as a pattern of emotional bonding between two individuals (e.g., parent–child, romantic partners, etc.). It can be used as a conceptual lens by which to view ED individuals and couples for several reasons. For example, women with EDs displayed anxious attachment patterns characterized by care seeking, as well as avoidant attachment patterns characterized by extreme self-sufficiency (Ward, Ramsay, Turnbull, Benedettini, & Treasure, 2000). These two patterns resulted in an overall pattern of attempting to draw others close while simultaneously pushing them away and are reflective of an overall insecure attachment style. Dick et al. (2013) cite research studies that support the belief that an insecure attachment style is common among individuals struggling with EDs. The literature is clear that attachment styles in childhood have a predictive quality for adult romantic relationships (Dick et al., 2013). As illustrated above, partners with Eating Disorders may already have anxious attachment patterns, which can have adverse impact on their romantic relationships. In romantic relationships, developing secure attachment styles starts from reprocessing emotional experiences and restructuring interactions to create mutual understanding to meet each other’s needs (Linville & Oleksak, 2013). Using attachment-based couple approaches (i.e., emotion-focused couple therapy) may aid the couple in strengthening their couple bond while simultaneously strengthening the Eating Disorder recovery processes. Emotionfocused therapy emphasizes the importance of expanding and reorganizing

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healthy connections and fostering the creation of a secure attachment bond between partners (Johnson, 2015). Importance of Couple-Based Treatment for Eating Disorders Researchers have demonstrated that family and other key social supports in an individual’s system significantly influence the onset, trajectory of, and recovery from an Eating Disorder (Linville & Oleksak, 2013). Couple relationship functioning is important in the management of ED symptoms (Dick et al., 2013). For adult clients with, or in recovery from, Eating Disorders, the relationship with a romantic partner may be the most significant relationship in one’s relational sphere and thus could provide valuable support for the healing process (Huke & Slade, 2006). Studies to date reveal that many adults with Eating Disorders experience a variety of difficulties in their committed relationships. Marital distress is common in relationships in which one spouse has an Eating Disorder (Bulik et al., 2011). Greater helpfulness of behaviors and higher relationship quality were indicative of higher partner support (Zak-Hunter & Johnson, 2015). Fischer and colleagues (2015) reported that partner acceptance/validation is helpful in the treatment process. As such, including partners in treatment to address EDs is important. It is clear from these studies that individuals who have recovered from Eating Disorders describe supportive relationships as vital to their recovery. Linville and associates found that while a majority of the partners with an Eating Disorder were currently receiving and had previously received therapy services or other forms of support, the noneating disorder partners rarely reported receiving such support (2016). This may indicate that there is insufficient access to care and an increased sense of isolation for partners or caregivers of a family member with an Eating Disorder. Partners commonly report difficulty understanding the Eating Disorder and find the secrecy surrounding Eating Disordered behaviors challenging to live with (Huke & Slade, 2006). Many describe feelings of powerlessness due to their rejected, well-intentioned attempts at supporting their loved partner (Kirby et al., 2015). Other consequences can include becoming fearful of saying or doing something hurtful or counterproductive, which can result in overall avoidance of the issue or a critical blaming stance towards the ED partner. Obviously, this can negatively impact the affected partner’s disordered eating behaviors. These challenges can cause increased distress and burden and may contribute to escalating conflict or issues in the relationship (Fischer et al., 2015). DSM-5 and Eating Disorders The Feeding and Eating Disorders section of the DSM-5 includes both Eating and Feeding Disorder diagnoses. These include six specific diagnoses:

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Pica, Rumination Disorder (RD), Avoidant/Restrictive Food Intake Disorder (ARFID), Anorexia Nervosa (AN), Bulimia Nervosa (BN), and Binge Eating Disorder (BED). Included are also two non-specific diagnoses: Other Specified Feeding or Eating Disorder (OSFED) and Unspecified Feeding or Eating Disorder (UFED). Here is the DSM-5 characterization of the three main specific Eating Disorder diagnoses: AN, BN, and BED, respectively (American Psychiatric Association, 2013). DSM-5 and AN Individuals with this Eating Disorder are characterized by significantly low weight, defined as less than minimally normal in adults, and less than minimally expected in children and adolescents, in the context of age, sex development, and physical health, due to persistent restriction of energy intake. The DSM-5 phrasing allows the clinician’s judgment to enter the picture as opposed to adhering to a rigid percentage of ideal or expected body weight as a criterion. In addition, individuals with AN tend to engage in persistent behavior that interferes with weight gain or may have intense fear of gaining weight or of becoming fat. Finally, they may lack recognition of the seriousness of their current low body weight or experience a disturbance in the way their body weight or shape is perceived and its impact on their self-evaluation (American Psychiatric Association, 2013). DSM-5 and BN According to the DSM-5, individuals diagnosed as having Bulimia Nervosa display three key characteristics. One, frequent indulgence in binge eating in which the individual eats larger amounts of food accompanied by a sense of lack of control over eating during these episodes. Two, resorting to compensatory behaviors, such as inducing vomiting, exercising, or the use of laxative agents and diuretics, due to fear of gaining weight. Three, binge eating occurrences are often prompted by low self-esteem issues due to a negative perception of one’s body image. These repeated episodes occur, on average, at least once a week for three months. Individuals diagnosed with Bulimia Nervosa are not necessarily underweight and are often at a normal body weight (American Psychiatric Association, 2013). DSM-5 and BED Individuals diagnosed as having BED  are characterized by experiencing repeated episodes of binge eating that include consuming an abnormally large amount of food in a short period of time accompanied by a loss of control over eating during the episode. These binge eating episodes occur, on average, at least once per week for three months. The episodes feature at

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least three of the following: consuming food faster than normal, consuming food until uncomfortably full, consuming large amounts of food when not hungry, consuming food alone due to embarrassment, and feeling disgusted, depressed, or guilty after eating a large amount of food. Overall, individuals feel significant distress about their binge eating. Those who struggle with Binge Eating Disorder do not show regular compensatory behavior associated with Bulimia Nervosa, nor do they binge eat solely during an episode of Bulimia Nervosa or Anorexia Nervosa (American Psychiatric Association, 2013). Couple Case Conceptualization Use of Attachment Theory Framework to Understand Relational Dynamics in Eating Disorders Attachment theory gives researchers and clinicians a framework with which to explore how EDs may be exacerbated, maintained, or helped within a couple’s relationship. Viewing EDs through an attachment lens also widens the issue from the individual to the larger couple-system by addressing relationships and emotional experiences as they relate to symptoms of the disorder (Linville & Oleksak, 2013). In order to build a conceptualization of how the ED functions beyond the physical manifestation, assessing for attachment history is crucial for therapists working with these clients (Tasca, Ritchie, & Balfour, 2011). Researchers have found that there are higher rates of insecure attachment in clients with EDs (Zachrisson & Skarderud, 2010). Two types of insecure attachment have been associated with ED behaviors: avoidant/dismissive attachment and anxious/preoccupied attachment (Tasca et al., 2011; Zachrisson  & Skarderud, 2010). Findings from a meta-analysis on attachment injuries and ED found that anxious/preoccupied attachment is most often associated with BN and its characteristic binging and purging behaviors, while avoidant/dismissive attachment is most often associated with AN and its restricting behaviors (Zachrisson  & Skarderud, 2010). Similarly, Ward et al. (2000) reported that eating-disordered patients displayed a mixed pattern of insecurity, reflecting both anxious/ambivalent and avoidant patterns. Anxious attachment patterns among some women with Eating Disorders have been found to lead to care-seeking among some and avoidant patterns among others. These patterns led to women with Eating Disorders to draw their partners close while simultaneously pushing them away. Obviously, this is both confusing and hurtful for the non-ED partner. Approaches and Interventions While there are challenges that face ED couples, fortunately there are specific interventions that have proved helpful in supporting relationship satisfaction

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and supporting the recovery of the ED partner in heterosexual couples. The support of the male partner in the treatment of the female can be a valuable part of the healing process, as the presence of empathic relationships, such as with a spouse, were significantly related to higher recovery rates in women with EDs (Bulik et al., 2011). The key is working with rather than against the woman’s partner. One way to do this is to invite the partner to play a supportive role in the process of treatment, which conveys the message that not only is the support and cooperation of the partner needed but also that he has a responsibility to help his partner (Dick et al., 2013). After reviewing several studies, Downs and Blow (2013) indicate that working with Eating Disorders requires ongoing training, supervision and support. Interventions should address education about EDs, sexual and communication concerns, and social support within the relationship (Dick et al., 2013). Education about the Eating Disorder is one of the first recommended interventions for couples. Partners of individuals suffering from an Eating Disorder would likely benefit from increasing their awareness and knowledge of EDs, to more effectively support their partners (Linville et al., 2016). Providing information on Eating Disorders may also increase partners’ motivation to become involved in the treatment process and in turn may motivate and encourage the struggling partner to alter her eating behavior (Dick et al., 2013). Education may also help decrease self-blame, helplessness, and negative emotions and encourage feelings of relief as partners learn that that there is no single factor that causes an Eating Disorder. Finally, both partners can find support for their feelings of hopelessness and/or helplessness, which are often common among ED couples (Dick et al., 2013). Couples should also be educated on how an Eating Disorder can affect a female’s sexual drive, including the effects of hormonal imbalances that may be the result of the Eating Disorder (Dick et al., 2013). Information needs to also include discussions on other factors that may contribute to sexual functioning, such as possible feelings of the ED partner of shame and unworthiness. Increasing awareness improves problem-solving skills, helping the couple avoid blaming, which improves their ability to connect at a deeper level (Dick et al., 2013). Another aspect of education addresses the impact of hurtful or harmful comments made by partners. ED partners indicated that they experienced negative feelings about their bodies when others made critical comments about them, and comments and pressure from partners about their bodies made recovery difficult (Dick et al., 2013). Therefore, educating partners on the potential impact of harmful comments, such as “You’re too fat or too thin” or “You look fine. It’s not like you’re fat or anything,” and on appropriate things to say can improve their effectiveness in supporting and helping their partners. Partners should avoid body or appearance-focused conversations (Dick et al., 2013).

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Positive social support from partners, friends, family, and health professionals contributes to the process of Eating Disorder recovery (Linville et al., 2016). Linville et al. (2016) point to the benefits of both partners receiving support services, which can be in the form of informational, emotional, or tangible support. Therefore, the couple need to be involved in interventions that increase their level of felt support as well as support. Linville et al. (2016) describe the Eating Disorder as a “third party in the relationship.” Additional couple interventions need to incorporate emotion regulation skill building, open couple communication, healthy coping responses, and psychoeducation for both members of a couple seeking Eating Disorder treatment. Normalization of the couple experience and externalization of the Eating Disorder is something the couple can combat together as a team, fostering a powerful therapeutic bond (Linville et al., 2016). One treatment modality with demonstrated empirical support for work with ED couples derives from cognitive–behavioral couple therapy (CBCT). CBCT has been demonstrated to assist a wide range of couples make adaptive changes in overall relationship adjustment and specific domains such as communication, and couple-based interventions from a CBCT perspective have also demonstrated efficacy in assisting couples with other psychological disorders, including those highly comorbid with AN, such as anxiety and depression (Baucom et al., 2017). Uniting Couples in the treatment of Anorexia Nervosa (UCAN) is one such intervention. UCAN was developed as a component of a multi-component treatment including individual CBT, medical management, and nutritional counseling. UCAN builds on existing treatments by incorporating principles from individual CBT for AN placed in an interpersonal context (Baucom et al., 2017). Uniting Couples in the Treatment of Anorexia Nervosa (UCAN) Bulik et al. (2011) developed a multifaceted model called Uniting Couples in the treatment of Anorexia Nervosa, or UCAN, which uses cognitive–behavioral couple therapy (CBCT) to work with the couple system over the course of 22 sessions. This approach is not a sole intervention, but complements individual therapy and work with a dietician and psychiatrist. The focus of the therapist using UCAN is to help the couple unite as a team to work toward recovery; the UCAN model consists of three phases that mark the transition of progress in therapy and prepare the couple for termination (Bulik et al., 2011). Phase 1 lays the foundation for later work, focusing on understanding the couple’s experience of AN, providing psychoeducation about AN and the recovery process, and teaching the couple effective communication skills; phase 2 focuses on the couple’s relationship and interactions around the ED to provide the support needed for the ED partner as they address the AN in individual treatment; and phase 3 addresses relapse prevention and termination (Bulik et al., 2011).

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UCAN builds on the support of a partner and the relationship in treatment by decreasing avoidance around AN, teaching the couple how to effectively address the Eating Disorder, and helping to foster a more satisfying relationship (Kirby, Fischer, Raney, Baucom,  & Bulik, 2016). Positive outcomes are perceived to be due to three broad mechanisms of change. Mechanism 1: bring AN out in the open to be addressed by the couple rather than being a solitary and secretive disorder. Mechanism 2: help the couple to work as a team in a variety of ways to address AN. Mechanism 3: reduce relationship distress as a chronic source of stress for the patient in order to facilitate recovery from AN (Kirby et al., 2016). Integrated Approaches to Treatment While CBCT models such as UCAN address the couple’s communication skills, they do not specifically address how to create emotional safety around challenging topics such as sexuality and body image that have been seen to trigger emotional escalation and have the potential to exacerbate ED symptoms (Linville  & Oleksak, 2013). Researchers note that using the UCAN model is particularly difficult with clients who struggle with emotional regulation, which can result in dropout and may increase the risk of engaging in ED behavior. These studies have found that ED symptoms such as restricting, binging, and purging are used as ways to regulate painful emotions (Linville & Oleksak, 2013). Therefore, difficulties with regulating emotion and fears around abandonment should be expected and may be better explained by the high rates of attachment injuries and trauma experiences (Zachrisson & Skarderud, 2010). Creating emotional safety within the couple system may be the most pivotal aspect of treatment if it is the case that emotional dysregulation leads to disconnect within the couple and increased use of ED behaviors for the ED partner. An integrated approach informed by attachment theory, such as emotionally focused therapy (EFT) (Johnson, 2015) and interventions of solution-focused therapy (SFT) that build on the couple’s strengths and resources for change may help to address the needs of couples dealing with EDs (Linville & Oleksak, 2013). EFT integrates the concepts of attachment theory into a model that seeks to actively restructure couples’ interactions in order to strengthen attachment bonds (Johnson, 2015). Eating Disorders can often be part of attachment injuries for couples, and individuals may also seek to meet their attachment needs through their EDs. Building secure attachment begins by reprocessing emotional experiences and restructuring interactions to create understanding and help partners more effectively respond to one another’s needs (Linville & Oleksak, 2013). Linville and Oleksak (2013) have proposed an integrated model utilizing EFT and SFT (SEFT) that is similar to the UCAN model in that it also proceeds over three phases as a multidimensional approach to ED recovery

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in couples and asks the couple to approach recovery from the ED as a team. Phase 1 involves creating a therapeutic alliance with both partners and expanding the emotional experience each partner has in relation to the ED; phase 2 focuses on externalizing the negative relational cycle of the ED and restructuring how the couple interacts around eating behavior and emotional needs; and phase 3 prepares the couple to face the challenges of ongoing recovery from the ED (Linville & Oleksak, 2013). Along with an individual therapist, medical provider, and dietician, the couple therapist will function as a member of a treatment team for clients with EDs as a way to address EDs in the various contexts in which they are maintained. Case Example: Ann and Jeff Ann, 41, and Jeff, 43, sought couple therapy to work through relationship concerns, mostly due to Ann’s ED, and to improve communication. Ann and Jeff had been in a committed dating relationship for five years; Ann moved in with Jeff and has been living with him for a year. Ann reported she was always “heavy” as a child and was often “teased” by her mother and sister about her weight growing up. She got married at the age of 20 and reported her husband at the time made degrading comments about her weight. Ann has one daughter from her marriage, who is now attending college. Ann got divorced after five years of marriage. She reported going on a diet after her divorce and exercising excessively, and as a result lost “more than 100 lbs.” Ann reported she was hospitalized several times during her 20s and 30s due to AN and depression symptoms. Due to receiving messages from family, close friends, and other relationships she was involved in, Ann continues to believe being “thin” is connected to feelings of positive self-worth and control. As a result, she engages in caloric restrictive behavior, which has become a contentious topic between Ann and Jeff. Trauma history was assessed early during therapy, and Ann reported verbal and emotional abuse by her father and her ex-husband. Her parents got divorced when Ann was 12 and the relationship with her father remains “distant.” Ann also reported receiving individual therapy services “off and on” since she was 8 years old, due to depression symptoms. Ann indicated that when Jeff argues with her or when he threatens to end the relationship, her ED symptoms and depression worsen. She described restriction and exercise as a way to regain control. Ann’s ED behaviors may be conceptualized as a way to achieve emotional regulation and distract from painful experiences without asking for her needs to be met by others, which could be understood as an attachment injury. There were times when Ann was unable to get her needs met by her primary caregivers in childhood, due to the marital discord and emotional and verbal abuse in her family of origin and her relationship with her exhusband, and she developed ways of self-soothing by using ED behaviors.

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However, this harsh method of meeting her emotional needs has also been a barrier to establishing meaningful and reciprocal relationships because she often isolates and disconnects from others when she is engaging in ED behaviors. Disconnecting by engaging in the ED is a primary concern for Ann in her relationship with Jeff, because they both have identified problems in their ability to communicate. Jeff has been divorced for 12 years and has two adult children from his previous marriage. He reported a contentious relationship with his ex-wife and, despite efforts to stay connected to his children, a distant relationship with his children. Jeff did not report any history of mental health concerns, trauma, or substance use. Even though Jeff reported worrying about Ann and experiencing some stress and anxiety about their relationship, he did not meet clinical criteria for anxiety. Jeff noted when he first met Ann, he found her attractive but thought she “could take better care of herself.” He enjoys buying clothes for Ann and “making her look beautiful.” Jeff reported wanting to help Ann and indicated he was concerned about their relationship. He has expressed feelings of helplessness when he sees Ann restricting food and tries to encourage her to eat more. In order to conceptualize their experience of the ED in the context of their relationship, it was necessary to gather information about both partners’ held beliefs, family experiences, trauma history, and how the ED is functioning within the relationship. Both partners reported experiencing patterns of feeling controlled and helpless. For example, Ann reported feeling that Jeff is “trying to control” her when he asks her to eat more or when he makes comments about how she is “too boney.” She also feels guilt for distressing Jeff with her ED and often hides her restricting behavior to avoid confrontation. Jeff also reported feeling Ann is in control when she refuses to go out to dinner with him or refuses to eat when he asks her to, expressing confusion about her restricting behavior as well as feeling powerless and helpless. In addition, Jeff and Ann expressed fears about the security of their relationship. Viewing the ED through the context of the couple allows the clinician to draw on strengths and resources of the relationship to work toward attachment and trauma healing. Utilizing an integrated approach to treatment based on SEFT, after helping the couple feel safe in therapy, the focus of early sessions (phase 1), was to identify the pattern or cycle which maintained the ED symptoms. Time was spent making sure that the couple had a consistent and accurate understanding of AN and of each other’s personal experience of the disorder. The couple was able to identify patterns of anxiety that fuel the interaction cycle. They were able to process how the secrecy and disengagement that often accompany EDs increased both partners’ fears about the relationship and, in turn, increased Ann’s ED symptoms. As Jeff pressured Ann, she withdrew, which increased Jeff ’s stress about the relationship and feelings of helplessness.

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In addition, treatment focused on building the couple’s understanding of their adaptive and maladaptive interactions around AN, and enhancing their communication patterns. Initial sessions were spent assessing Ann’s AN-related thoughts, feelings, and behaviors, along with her overall low selfworth. A safe and supportive context was created for Ann to disclose her EDrelated experiences and for Jeff to more effectively understand Ann’s struggles. This in turn provided the context for them to work more effectively as a team. Next, treatment addressed the couple’s communication, educating the couple on ways to be open and accepting of their emotional experiences with one another in an effective manner as well as how to listen actively to each other. Jeff and Ann were able to communicate their fears of abandonment and sense of being overwhelmed by one another’s behaviors. As anxiety decreased between Ann and Jeff, work began on restructuring the cycle (phase 2). Treatment then focused on helping Ann and Jeff address specific AN-related challenges together as they discussed how to approach meal time, avoiding comments about Ann’s physical weight and caloric intake. The couple also addressed issues related to Ann’s negative body image, the struggles the couple had with their physical relationship and sexual intimacy. Processing their needs in sessions decreased the maladaptive behavior patterns outside of therapy. Jeff reduced comments about Ann’s eating or her “thinness,” and in turn Ann used positive coping skill to regulate her emotions decreasing the need to engage in ED behavior. As their ability to express their fears openly increased their level of understanding, their ability to provide support to one another also increased. They were able to conceptualize their relationship more positively as a source of security. This outcome reflects Linville and colleagues’ (2016) suggested theoretical model, described earlier, indicating that as participants felt more stable in their relationship, both their Eating Disorder symptoms and the impact of the Eating Disorder on the relationship decreased. The relapse prevention sessions (phase 3) focused on a number of areas. For example, the couple was encouraged to share their expectations and concerns with one another directly, instead of arguing or avoiding potentially sensitive conversations. In their final session, the couple reflected on their experience in treatment. They expressed feeling they were on the same team working against the ED. They reported feeling more connected in their relationship as a result of treatment. Note how the treatment approach utilized also mirrored UCAN’s mechanisms of change described earlier where positive outcomes are perceived to be due to bringing AN out in the open to be addressed by the couple rather than being a solitary and secretive disorder; helping the couple work as a team in a variety of ways to address AN; and reducing relationship distress as a chronic source of stress for the ED partner in order to facilitate recovery from AN (Kirby et al., 2016).

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Conclusion Couples affected by an Eating Disorder reported that there were substantial and reciprocal influences of their relational dynamics and Eating Disorder illness and recovery processes (Linville et al., 2016). This points to the importance of examining and treating Eating Disorders in the context of a couple relationship. Couples where one partner struggles with an ED may experience a variety of interpersonal problems, and when working with these couples, issues concerning difficulties with intimacy and maintaining relationships need to be addressed (Dick et al., 2013). Issues such as how to support recovery versus the Eating Disorder and how to navigate social support systems as a team need attention in the therapy room (Linville et  al., 2016). Applying treatment models that are informed by attachment theory and CBCT would aid in the healing of attachment injuries, promote emotional regulation, and strengthen the couple bond, paving the way to establish long-term recovery from EDs (Linville & Oleksak, 2013). References American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author. Baucom, D. H., Kirby, J. S., Fischer, M. S., Baucom, B. R., Hamer, R., & Bulik, C. M. (2017). Findings from a couple-based open trial for adult anorexia nervosa. Journal of Family Psychology, 31(5), 584–591. doi:10.1037/fam0000273 Bulik, C. M., Baucom, D. H., Kirby, J. S., & Pisetsky, E. (2011). Uniting Couples (in the treatment of) Anorexia Nervosa (UCAN). International Journal of Eating Disorders, 44(1), 19–28. doi:10.1002/eat.20790 Dick, C. H., Renes, S. L., Morotti, A., & Strange, A. T. (2013). Understanding and assisting couples affected by an eating disorder. American Journal of Family Therapy, 41(3), 232–244. doi:10.1080/01926187.2012.677728 Downs, K. J., & Blow, A. J. (2013). A substantive and methodological review of family‐based treatment for eating disorders: The last 25 years of research. Journal of Family Therapy, 35(Suppl 1), 3–28. doi:10.1111/j.1467-6427.2011.00566.x Fischer, M. S., Baucom, D. H., Kirby, J. S., & Bulik, C. M. (2015). Partner distress in the context of adult anorexia nervosa: The role of patients’ perceived negative consequences of an and partner behaviors. International Journal of Eating Disorders, 48(1), 67–71. doi:10.1002/eat.22338 Huke, K., & Slade, P. (2006). an exploratory investigation of the experiences of partners living with people who have Bulimia Nervosa. European Eating Disorders Review, 14(6), 436–447. doi:10.1002/erv.744 Johnson, S. M. (2015). Emotionally focused couple therapy. In A. S. Gurman, J. L. Lebow, D. K. Snyder, A. S. Gurman, J. L. Lebow, & D. K. Snyder (Eds.), Clinical handbook of couple therapy (5th ed., pp. 97–128). New York, NY: Guilford Press. Kirby, J. S., Fischer, M. S., Raney, T. J., Baucom, D. H., & Bulik, C. M. (2016). Couple-based interventions in the treatment of adult anorexia nervosa: A brief case example of UCAN. Psychotherapy, 53(2), 241–250. doi:10.1037/pst0000053

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Kirby, J. S., Runfola, C. D., Fischer, M. S., Baucom, D. H., & Bulik, C. M. (2015). Couplebased interventions for adults with eating disorders. Eating Disorders: The Journal of Treatment & Prevention, 23(4), 356–365. doi:10.1080/10640266.2015.1044349 Linville, D., Cobb, E., Shen, F., & Stadelman, S. (2016). Reciprocal influence of couple dynamics and eating disorders. Journal of Marital and Family Therapy, 42(2), 326–340. doi:10.1111/jmft.12133 Linville, D., & Oleksak, N. (2013). Integrated eating disorder treatment for couples. Journal of Couple & Relationship Therapy, 12(3), 255–269. doi:10.1080/1533269 1.2013.806709 Tasca, G. A., Ritchie, K., & Balfour, L. (2011). Implications of attachment theory and research for the assessment and treatment of eating disorders. Psychotherapy, 48(3), 249–259. doi:10.1037/a0022423 Thompson-Brenner, H. (2016). Improving psychotherapy for anorexia nervosa: Introduction to the special section on innovative treatment approaches. Psychotherapy, 53(2), 220–222. doi:10.1037/pst0000050 Ward, A., Ramsay, R., Turnbull, S., Benedettini, M., & Treasure, J. (2000). Attachment patterns in eating disorders: Past in the present. International Journal of Eating Disorders, 28(4), 370–376. doi:10.1002/1098-1108X(200012)28:4  3.0.CO;2-P Zachrisson, H. D., & Skårderud, F. (2010). Feelings of insecurity: Review of attachment and eating disorders. European Eating Disorders Review, 18(2), 97–106. doi:10.1002/erv.999 Zak-Hunter, L., & Johnson, L. N. (2015). Exploring the association between partner behaviors and eating disorder symptomology. Families, Systems, & Health, 33(4), 405–409. doi:10.1037/fsh0000147

12 THE SEXUALLY DISORDERED COUPLE Shannon B. Dermer and Molli E. Mercer

A

lthough genital-focused sex can and often does involve eroticism and pleasure, many people find sexual pleasure in a variety of sexual activities, a variety of sexual stimuli, and a variety of sexual targets (e.g., older men, younger women, people of a particular race or ethnicity). When non-genital sexual desires and behaviors are equal to or exceed interest in genital-focused sexuality, it is considered non-normative and labeled “paraphilic” (American Psychiatric Association, 2013). Paraphilia are not necessarily problematic; they are just considered nonnormative. Some paraphilia may be statistically unusual, but they are not inherently more healthy or less healthy than any other sexual desires and behaviors; paraphilia are pathologically neutral (Nichols, 2014). However, when persistent, intense sexual interests and preferences cause distress and are non-consensual and/or harmful to a person’s psyche or body, they can be diagnosed as Paraphilic Disorders (American Psychiatric Association, 2013). In this chapter the definition, history, and controversies revolving around paraphilia will be discussed, as well as how to differentiate between paraphilia and Paraphilic Disorders, and how to assess, diagnose, and intervene with Paraphilic Disorders from a systemic perspective. Overview: Theory and Research on the Paraphilic Disorder Couple

Each individual and couple has their own erotic blueprint (Perel, 2014). When an individual’s or couple’s blueprint diverges from the idealized version of what a society states “normal” sexual desires, behaviors, and relationships should be, those blueprints are likely to be labeled different, deviant, or possibly disordered. Nevertheless, research has shown that many people’s

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blueprints include what has been termed “kinky sex” (Nichols, 2014). The term kink includes bondage and discipline, dominance and submission, and sadism and masochism (BDSM), and fetishism. Kinky sex is sometimes juxtaposed with “vanilla sex,” which is used to refer to commonplace or mundane sex (opposed to provocative and adventurous sex). The vulnerability, security, safety, and communication skills needed to share desires for kinky sex and to explore kink with one another means that kinky couples tend to be more emotionally and sexually attuned to one another. Wismeijer and van Assen (2013) found that people involved with kink tended to be more extraverted, open to new experiences, less neurotic, less sensitive to rejection, and more securely attached than those who engaged in vanilla sex. Overall, couples can learn the following from kinky couples: communication and negotiation; being sexually non-judgmental (open to new experiences, mutual trust and openness, and not engaging in shame—a partner may not be interested in particular fantasies or behaviors, but they do not shame their partner for being interested); engaging in sexual variety; ability to plan for sex without detracting from enjoyment; technical skills (learning sexual technique rather than believing that sexual skills should be natural); and sex as a form of healing and spirituality (Nichols & Fedor, 2017). Paraphilic Disorders In order to be diagnosed with a Paraphilic Disorder based on the DSM-5, a person must meet the qualitative description of a paraphilia, and associated urges, fantasies, and behaviors must be intense and recurrent over at least six months. The paraphilia must also result in negative consequences, typically involving: significant distress, obsession, guilt, shame, anxiety, and/ or paraphilic interests that result in problems with significant relationships, are non-consensual, and/or cause significant impairment with interpersonal relationships, social relationships, or with major systems (e.g., legal, education, vocation). These two requirements (intensity and length of duration, and distress/impairment) should be applied to each of the disorders described below. Two specifiers can be added to all Paraphilic Disorders: “in controlled environment” (they live in a setting where their paraphilic activities are restricted) and “in remission” (no distress or impairment for at least five years while in an uncontrolled environment). There are many paraphilias, but there are only eight Paraphilic Disorders: voyeuristic, exhibitionistic, frotteuristic, sexual masochism, sexual sadism, pedophilic, fetishistic, and transvestic disorders (in addition to other Specified Paraphilic Disorders and Unspecified Paraphilic Disorders). Voyeurism involves intense sexual urges and desire from observing people naked, disrobing, or engaging in sexual activity without the consent of the person/people being observed. Exhibitionists have the urge to or derive pleasure from

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fantasizing about or actually exposing their genitals to unsuspecting persons. There are several subtypes of exhibitionistic disorder: sexually aroused by exposing genitals to prepubertal children; exposing genitals to physically mature individuals; or sexually aroused by exposing genitals to both prepubertal children and physically mature individuals. Frotteuristic disorder manifests itself through persistent urges, fantasies, or behaviors involving touching or rubbing against a nonconsenting adult. Although sexual sadism and sexual masochism disorders are separated in the DSM-5, they are presented together here in that they are polar opposites in regard to getting sexual arousal and/or pleasure from the physical or psychological suffering of others or getting sexual arousal and/or pleasure from experiencing physical or psychological suffering, by inflicting or receiving acts of humiliation, beatings, bondage, and/or suffering. Pedophilia is sexual arousal focused on a prepubescent child or children, usually under the age of 13. People diagnosed with pedophilic disorder may be exclusively or nonexclusively attracted to children, may be attracted to males, females, or both, and may be attracted to children with whom they are related (incest) or to children with whom they are not related. Each of these can be used as a specifier. Fetishes are typified by sexual desire, arousal, and gratification associated with nonliving objects or non-genital body parts. Examples of what people may be attracted to include rubber, latex, leather, dirty undergarments, hair, feet, ankles, and ears. Clinicians should not include people who are aroused by cross-dressing in this category, nor should they include arousal and gratification associated with devices designed for stimulation of the genitals (e.g., vibrators and dildos). In the diagnosis, clinicians can specify whether the fetish involves body part(s), nonliving object(s), or other. People who cross-dress may or may not have that behavior labeled as a paraphilia and may or may not be diagnosed with a disorder. In order to be labeled a paraphilia, the person must get sexual excitement from fantasies of cross-dressing or from actually cross-dressing and must be accompanied by the other required characteristics of a disorder in order to be diagnosed. In addition to the typical specifiers, a clinician can also specify “with fetishism” (sexual arousal from specific fabrics, materials, or garments) or with autogynephilia (sexual excitement from thoughts or images of self as a female or from fantasizing or behavior that mimics or exhibits stereotypically female biological functions [e.g., breast feeding, lactation, menstruation], feminine behavior, or possessing female anatomy). Characteristics of and symptoms of Paraphilic Disorders that do not fit the full, qualitative descriptions of the other Paraphilic Disorders may be designated as Specified or Unspecified Paraphilic Disorder. Examples might be autonepiophilia (sexual urges and arousal related to regressing to infantilistic behaviors, play, and or clothing), zoophilia (animals), or urophilia (urine). If the clinician specifies the paraphilic urges, fantasies, or behaviors, then it is another Specified Paraphilic Disorder. If for some reason the

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clinician chooses not to specify why characteristics are not met or there is insufficient information to make a more specific diagnosis, then it is an Unspecified Paraphilic Disorder. Assessment Considerations Assessment is influenced by the theories and models to which one subscribes. From a general systems perspective, a therapist would assess each individual, the couple, their families-of-origin, and possibly other related systems influencing the couple (e.g., medical systems, social services, military) and the presenting concern. Information can be collected through clinical interviews, observation of discussions between the couple, questionnaires, and physical/medical tests (e.g., hormone levels; tumescence; vasocongestion and heart rate when shown various sexual materials). Overall, the clinician may ask questions about the individual biological, individual psychological, couple, intergenerational, and environmental domains (Page, Dermer, & Bachenberg, 2017). Individual Biological Domain The biological domain includes biological, physiological, and medical factors that may affect people’s past and current sex lives. Though perhaps less important than if someone was experiencing sexual dysfunction, assessment in this domain may still be important and yield useful information. Clinicians should ask about medications, nonprescription drugs, health problems, changes in hormones, and any past issues that may relate to paraphilia and/ or Paraphilic Disorders. Although family values will be discussed under the intergenerational domain, it may also be useful to ask about any family medical issues that occurred during a person’s sexual development. For example, perhaps someone connects paraphilic interest in latex back to spending a lot of time in a hospital when he or she was young. Connecting sexual interests to an explanatory event may be helpful but is not required or even always useful. Individual Psychological Domain Distress and impairment related to a Paraphilic Disorder may be related to personal issues, sexual experiences, sexual and gender orientation, and/or mental health. The clinician should explore people’s experiences, ­perceptions, and values related to gender and sexual orientation and sex. It is also important to assess sexual urges, fantasies, sexual preferences, ideas about consent, criminal behavior and/or prosecutions, body image, self-esteem, use of pornography, frequency of sexual behaviors (including masturbation), and (of course) the development of the paraphilia and/or Paraphilic Disorders and associated distress/problems. Many of these things can also be discussed in the couple domain or possibly in the environmental domain.

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Although people with unusual sexual interests are no more likely to have had abusive or traumatic pasts than the general public, past trauma, sexual secrets, abuse, and past interpersonal violence should be assessed in the case of harmful paraphilia or when there is distress generated by what would typically be a benign paraphilia. In addition, it is important to assess any co-occurring disorders. Couple Relationship Domain The couple’s current relational and sexual satisfaction should be assessed. In addition, the clinician may want to explore couples’ attachment, emotional, and, conflict resolution styles, as well as their power dynamics and relationship and intimacy expectations. Other important areas of assessment include their strengths as a couple, preferences for eroticism and sexual pleasure, the meaning they attribute to sex and their own sexual interests (specifically the paraphilia), and their relational and sexual goals for their relationship. Overall, the clinician should assess their sexual and emotional attunement and individual/couple feelings of security. How much insight do they have into their own emotions, sexual desires, and sexual values, and how well do they know each of these areas for their partners? How good is each person at expressing his or her personal and sexual wants and needs? Does each person make it safe for the other person to be vulnerable? Does each person feel emotionally and physically safe? Are they able to each effectively identify and follow the other person’s verbal and non-verbal cues? Intergenerational Domain Families send intentional and unintentional messages about relationships, sex, and sexuality. The clinician should explore what conversations fami­ lies explicitly had with each member of the couple about reproductive and ­ leasure, non-reproductive sex, sexual orientation, gender expression, sexual p physical and non-physical intimacy, and religious views on sexual ­behaviors and sexuality. In addition, were family members’ actions congruent or incongruent with their verbalized values? What did each person learn about intimacy, affection, relationships, and sex by observing family members’ actions? Were their families generally sex positive or sex negative? What does hav­ ing similar or different sexual values to their families mean to them? How similar or different are the couple’s familial backgrounds (in relation to views of sexuality) and how similar or different are the couple’s values? How did they see family members treated who did not conform to the general family values? Have they discussed their sexual values and behaviors with family members or are they a secret from family? If a secret, how has that affected their relationship with family members? What would they do if they found out about the individual’s/couple’s sexual secrets?

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Environmental Domain People’s personal identities intersect with society, culture, history, and religion. People internalize messages from families, media, education, laws and policies, etcetera. In addition, sexual values and sexual activities may be treated differently depending on one’s personal identities. It may be helpful to deconstruct with clients their values and who/what influenced those values. While unpacking those values, it would also be helpful for clinicians and clients to discuss which ideas and values are non-negotiable and which are up for discussion and possible change. As part of deconstructing client values, it is also important for clinicians to examine and evaluate their own values, which may unfairly influence their assessment of the individuals/ couple and their sexuality. Case Conceptualization The basis for discussing, assessing, and possibly intervening with Paraphilic Disorders is differentiating between what is harmful (to self and/or others), what is unusual, and what is acceptable or unacceptable to each individual and the couple as a system. Each person is an individual in a relationship, but they form a new system when they become a couple. Along with each person’s personal history and beliefs come their families-of-origin and the interaction between the couple and their associated families-of-origins. Coupling is not just two individuals coming together in a relationship—it is two individual systems blending to make a unique, new system. Cultural Considerations It is important to understand how views of sexuality are impacted by society, individual and couples’ cultural backgrounds, and legal/medical/psycho­ logical influences. In addition, what is acceptable in one group or culture may not be acceptable in another. Thus, clinicians have to consider how people’s identities intersect with societal biases and assumptions to create different sexual realties for individuals and couples. Heterosexism, ageism, racism, ableism, and other – isms create different realities for people, and these realities can have negative, impactful consequences on both individual and couple’s sexual expression. Treatment Considerations Clinicians can target the individual’s and/or couple’s values, perceptions, urges, desires, distress, and behaviors for intervention. There are many types of interventions for Paraphilic Disorders, including: behavioral, cognitive– behavioral, attachment-based, systemic, narrative, and pharmacologic (for dangerous Paraphilic Disorders) therapies.

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From a systemic perspective, the couple relationship is where core relational and sexual needs are expressed (Perel, 2014). It is important to honor people’s sexual desires and help couples negotiate (when possible) differences in their sexual desires. Perel (2014) suggests exploring sexual fantasies, depathologizing consensual sexual preferences, and helping clients understand sexual metaphors by connecting them to past and current emotional needs. She believes that fantasies are a metaphor for emotional needs and offer a complex source of information for assessment and intervention. Case Example: Doug and Christa Doug (31) and Christa (30) were a European American, Christian, middleclass couple, both with college degrees who sought counseling to discuss having children. They had dated for two years before getting married and had been married for six years. During their first session they discussed their presenting concern. Background information was collected during the second session. It was during the third session Christa “outed” herself and Doug as a couple struggling with paraphilia. Both Christa and Doug enjoyed kinky sex, and for the most part it had strengthened their marital and sexual relationship. Christa liked to dominate and control Doug, and sometimes she liked to be submissive and engage in activities that caused her minor levels of pain. She sometimes liked to be told what to do, spanked before or during sex, and occasionally wore a dog collar and leash. Her desired activities were confined to the bedroom as foreplay or as an enhancement to sex, and she stated that “she didn’t have to have” that type of kink, but she enjoyed it on occasion. When she wanted to be dominated, she would dress differently and talk differently to let her husband know she wanted to engage in this type of sexual activity. Doug was sexually attuned to Christa’s way of dressing and talking and engaged in domination, control, and mild sadistic activities to enhance her sexual pleasure. Doug liked to engage in paraphilic infantilism (autonepiophilia). He found it sexually arousing to be treated like an infant. He liked to wear a diaper, be burped, held and rocked, and fed by Christa. He also liked to sometimes defecate or urinate in his diaper and have Christa clean him and re-diaper him. Christa and Doug had intercourse or oral sex two to three times a week. They usually engaged in the infantilistic behaviors in the beginning of the week and that kept Doug’s “motor running” for the rest of the week. They did not engage in these behaviors every time they wanted to have sex. Christa was sexually attuned to Doug’s cues that he wanted to engage in these types of sexual fantasy and activity—he would usually start using baby talk to indicate his urges. Doug liked to be taken care of for several hours before they engaged in intercourse or oral sex. These activities were not confined to their bedroom; it was part of their routine for the day and evening.

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Doug did not reveal his interest in infantilism until after they were married. Christa was at first shocked because he never asked for this while they were dating and felt deceived. She had been open about her urges and desires for dominance, control, and minor masochistic activities while they were dating. The fact that she was open about desire for kinky sex and he was not forthcoming about his desires bothered her. He stated that he did not reveal this because when he had done so in previous relationships his partners quickly ended the relationship. Once the couple worked past Christa’s feelings of hurt, they slowly began to introduce infant/caretaking behaviors into their sex lives until they had increased the intensity of the role-play and behaviors to a level he desired and with which she was comfortable. Approximately a year before they sought counseling, the couple begun to discuss having children. As they began to more seriously discuss the couple stopping contraception, they both became more anxious about Doug’s infantilism. Doug agreed to having a child, but Christa sensed his hesitation and this was causing some problems in their relationship. Doug was willing to negotiate some of his sexual desires, but he was worried he would not get enough attention once the baby was born and was distressed at the idea of how they would maintain their sexual relationship as the child got older. They both feared he would be jealous of the baby. As they discussed having a baby more seriously, Doug wanted to engage in infantilism behaviors more often and found himself more preoccupied with infantilistic fantasies. He and Christa had been arguing more, he was having trouble sleeping, and he reported feeling anxious on most days. He had been reprimanded at work several times for not finishing projects on time. Doug stated that this was because of his anxiety and because he was preoccupied with fantasizing about Christa “babying” him. DSM-5 The fact that Doug and Christa liked to engage in kinky sex did not constitute a disorder (or even a paraphilia), but the fact that the infantilism was persistent, intense, and equal to or exceeding his interest in normophilic sex, and started to cause significant distress for Doug and his relationship with Christa, meant a Paraphilic Disorder should be considered. Doug had engaged in infantilistic sexual fantasies and behaviors on and off since he was in his 20s. Infantilism is a paraphilia, but does not fit with the eight Paraphilic Disorders described in the DSM-5. Because the paraphilia was intense, persistent, had lasted more than six months, and was causing distress, Doug could be diagnosed with other Specified Paraphilic Disorder, Autonepiophilia. The other Specified Paraphilic Disorder is used when the sexual urges, fantasies, and/or behaviors do not meet the criteria and qualitative description for one of the eight Paraphilic Disorders.

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Christa enjoyed both being dominated/controlled by her husband and dominating/controlling him, and she enjoyed low levels of pain. Although these interests have been persistent over the years, the intensity is relatively low. Her interests may be better characterized as preferential sexual interests rather than a paraphilia. If the behaviors and interest were more intense and exceeded her interests in normophilic sex, her interests could be described as a benign paraphilia and would only rise to the level of a Paraphilic Disorder if some day it caused significant distress or impairment in her social, occupational, or other important areas of functioning. Assessment Considerations As already mentioned, the persistence, intensity, and distress associated with both clients’ sexual interests were assessed through clinical interviews. This also could have been done with self-report inventories, but both clients were forthcoming with information and the couple agreed with each other’s assessments of sexual interests. Christa’s sexual interests, although slightly unusual, did not meet the level of a paraphilia. Doug’s sexual interests did rise to the level of a paraphilia and because of the associated distress was diagnosed as a Paraphilic Disorder. In preparing to help the couple discuss possible interventions, it is helpful to gain insight into the needs that are being met by their sexual relationship and sexual interests. Both members of the couple reported that they viewed sex as an intimate part of their marital relationship that helped differentiate their relationship from other close connections. They saw sexual activities as a way of increasing their already strong relational intimacy. They also both conceptualized sex as something that should be fun and exciting, as well as meeting their physical, emotional, and relational needs to be close. Doug also emphasized the sexual relationship as a way of feeling taken care of. He explained that he had been abandoned by his biological parents as a child and grew up in multiple foster homes until the age of five, when he was adopted. His parents provided a good home, were caring, and supported him. However, he described his father as being physically distant as far as showing any type of physical affection, and he rarely expressed verbal affection. His father also made it hard for his mother to express verbal or physical affection. He believed that if you coddled a child too much that it made him weak. Although Doug described his parents as moderate (not particularly liberal or conservative), they did not discuss sex (he learned about sex at school and from friends), and his parents rarely expressed physical affection in front of him. Doug reported that he relished the times when his mother did show him physical affection—usually when his father was out of town or when Doug was sick. Doug became sexually active at 16. He remembered always enjoyed cuddling before and after sex, but his enjoyment for

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cuddling transitioned more into wanting to be held and treated like a baby sometimes. This caused problems in his sexual relationships. Christa reported that her parents were affectionate and open about sex. Christa was the oldest of five children and often helped her parents take care of her younger siblings. She also exceled in school, was organized, and enjoyed being needed by others. While she enjoyed being needed by others, she sometimes became tired of being the “responsible one” and taking care of so many people and so many things. Sometimes she just wanted to not be in charge and have someone else take control. When she was younger, she would fantasize about someone controlling her during sex and about light bondage. She became sexually active at 18 and began integrating partners holding her down and causing light pain (light biting, pinching her nipples, causing hickeys, and light spanking) in her early 20s. Soon after she began enjoying these activities, she met Doug. They integrated these sexual preferences into their sexual life and experimented with her being more submissive and Doug being more dominant and in control sometimes. Later, when she started fulfilling Doug’s infantilistic preferences, she learned to enjoy taking a more caretaking and controlling role at times with Doug. The couple reported that they were satisfied in their relationship overall. They had a close relationship and communicated well. They were emotionally attuned to one another and sexually attuned. Their recent problems were mostly caused by getting stuck in a typical transitional stage of coupling— becoming a family. Case Conceptualization From a systemic perspective, one has to consider the current interaction between the couple, how the couple is influenced by patterns in their familyof-origin, and how societal and cultural views influence their couple functioning. Whenever there are exits or entries into a family system, new rules, roles, and boundaries may have to be negotiated. Having a child meant that each marital partner would also now be a parent, and this would change their relationship. Instead of just taking care of each other, they would have another person competing for their time, energy, and affection. In addition, although they did not verbalize this, they also knew that it was less “acceptable” to engage in these behaviors when the privacy of their relationship would be lessened with a child in the home. Children observe their parents, ask questions, and often speak about what they see inside the home to those outside the home. Even if Doug were not jealous of the time Christa spent caretaking of the child, what would that child say about Daddy’s sippy cup? What if the child caught Christa rocking Doug and treating him like an infant? Would having an infant and caretaking of he/she be triggering for Doug given his infantilism? Additionally, there would be more restrictions on how, where, and when they expressed their sexual interests.

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In addition, part of Doug’s distress may have been an activation of past experiences where he was rejected and felt unsafe to reveal and/or act on his urges, fantasies, and desires. In the early years of his life he did not have consistent caretakers to meet his attachment needs; his father sometimes scolded Doug (and his mother) for expressing the need for attachment behaviors and distanced from Doug during these times. In addition, Doug was rejected by several dating partners after he made himself vulnerable and revealed his desires. He held back with Christa until he had the security of a marital relationship before he revealed his intense desire for exaggerated attachment behaviors from a partner that mimicked a parent–child relationship rather than a partner relationship (during their times of infantilistic play, but not in the relationship overall). The infantilism was a metaphor for his unmet attachment needs from caretakers. While Doug thought that Christa was a safe person to enact these needs, the idea of bringing a baby into the family re-activated his fears that his needs would be rejected and/or unmet. Cultural Considerations Many of their concerns about how life and their sex lives would change after a baby are typical concerns of soon-to-be parents. However, because of the societal stigma related to their sexual interests, it magnified their concerns. Many individuals tend to get even more uncomfortable with unusual sexual interests when they relate to children or what they perceive as violence—though infantilism should not to be confused with pedophilia. Doug was not sexualizing infants/children; he was sexualizing being taken care of like an infant. In addition, Christa was not sexualizing being in an abusive relationship; she was sexualizing the relinquishment of control and enjoying the enhancement of sexual pleasure through experiencing mild pain. As a middle-class, European American, educated couple, Doug and Christa did not think they were affected by cultural biases related to their identities, with the exception of gender and general negative societal views of paraphilia (especially infantilism). Doug thought that it was less acceptable for men to want to be held, comforted, and taken care of in “weak” ways. It was okay for wives to make their husbands dinner, but not to rock them and console them. Doug thought many would not consider him masculine or a real man because of his sexual desires. He also knew his particular sexual interests would be judged more harshly than other paraphilia. Christa expressed that society is harsher on mothers than fathers and that if people found out about Doug’s interests, once they had children, she would be judged for not protecting her child from aberrant desires and activities. In addition, she thought people would see her as a weak woman for her sexual interests, which did not mesh with her view of herself as a strong woman.

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Treatment Considerations The couple already had many strengths and were able to negotiate past relationship transitions, but had become immobilized when discussing the new boundaries, roles, and expectations associated with having children. They were both worried that their roles as parents would be incompatible with their current sexual blueprints. Interventions included normalizing this transition and associated fears so that the couple could use their own strengths to negotiate this new life stage. In addition, the therapist discussed the metaphors interwoven in their sexual fantasies and behaviors and how those needs (represented in the sexual metaphors) could continue to be met in the same and slightly different ways. The therapist also discussed the cultural implications of infantilism and having children. There is more pressure to curb paraphilia and, in particular, infantilism because of society’s fears around atypical sexuality and children. The first thing the therapist did was discuss typical family transitional stages and how that was intersecting with their sexual blueprints. The couple had negotiated their lovemaps successfully, but their life stage was challenging their negotiation skills, leaving the couple feeling stuck. The perception of being stuck in what appeared to be an untenable situation was distressing the couple and had risen to significant levels for Doug. The clinician helped the couple discuss how their individual and couple needs for sexual intimacy and closeness could continue to be met, even if they had to make adjustments. Although parents often show physical affection in front of their children, in many Westernized cultures they do not typically show overtly sexual behaviors in front of their children. The therapist discussed with the couple that it was typical for couples to have less freedom to express some of their sexual interests whenever they wanted once children were born, but that did not mean they could not express them at all. The couple discussed which sexual interests they would continue with and how they could get some of their needs met through non-sexual behaviors. Both agreed that they could continue many of their sexual activities with children in the household, but that they would be confined to the bedroom (unless the children were not home). Both Doug’s and Christa’s parents lived nearby, so they discussed their child spending time with Grandma and Grandpa and using some of that time to connect as a couple and express their sexual interests freely. Christa emphasized that her sexual urges to be dominated and controlled were less than her husband’s urges to be babied; however, she believed they could still engage in her sexual interests even with children (she would just hide the collar and leash). In addition, she conceded that it could be foreplay for Doug to sometimes take over full responsibility for what needed to be done in the household and tell her what he wanted her to do to assist. They agreed that it would be fun to show their children that both men and women

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could be in charge of the household and trade off at times. It would add to some of the fun in their relationship for that to be secretly part of their foreplay, unbeknownst to their child or anyone else who was visiting the household. They both agreed that secretly role-playing “in plain sight” could be an interesting way of adding new sexual tension to their relationship. They were already very sexually attuned to each other’s verbal and non-verbal sexual cues and could have their own secret ways of letting the other person know that they were engaging in role-play foreplay. As far as Doug’s sexual blueprint, many of his needs could also still be met, just in slightly different or less intense ways. For example, rather than “babying” him anywhere in the house, that behavior would be restricted to the bedroom. However, Christa would continue to be sexually attuned to his needs for babying and do some things in more covert ways until they could be alone. For instance, she could rub his back in front of others in a swirling motion like one would do for a child, but that is also acceptable for an adult. She could place his food on his plate for him, cuddle with him while they were watching tv, call him by pet names, and give him a playful spank on his bottom if he was misbehaving. In the bedroom she would let him use a sippy cup, burp him, rub his back, hold him, and talk to him like he was a baby, but she would prefer that he not wear diapers and she no longer wanted to change his diaper. Doug asked if she would be okay with him sometimes wearing adult disposable underwear underneath his clothes. They would not be easy for other people to detect, but would give him close to the feeling of wearing a diaper. She agreed. Overall, the couple and therapist discussed how important it would be to revisit their sexual blueprints, if they were sexually satisfied, if their needs for sexual pleasure and sexual intimacy were still being met, and double-check that they were continuously working on staying attuned to each emotionally and sexually, even with the added changes of caring for a child. Although roles, expectations, and behaviors may have to change for every couple over time, they could still find ways to meet their core individual and couple needs in the best ways possible. Clinical Outcomes The presenting concern for this couple was less about their actual sexual interests and more about anxiety and stress related to changing expectations and the fear that sexual blueprints would no longer be honored or fulfilled. In some ways, Doug may have feared Christa wanted children more than she wanted him; Christa may have feared Doug’s sexual interests were more important than having children. Their fear and anxiety propelled them into a stuck position, and they were scared that their sexual blueprints and desire to have children were mutually exclusive. When individuals’ relational coping skills become overwhelmed, they often take polarized positions that

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are unnecessary and are unable to use strengths that are at their disposal and have been successful in the past. Once some of the couple’s fears were allayed, they were able to use their already successful emotional attunement and communication skills to find ways that they could have children and be secure that their sexual, relational, and attachment needs could still be met. Both Doug and Christa let the therapist know that they appreciated her help in becoming unstuck and they appreciated her support and making therapy a safe place for them to discuss their sexual interests. In early sessions Doug wanted to focus on their concerns about having children without bringing up their sexual interests, but that only made the couple feel more stuck and the therapist confused about why they could not work past this issue. They commented that when Christa finally “outed” them that the therapist “didn’t even flinch,” and they were impressed and excited that she was not put off by their issues. They felt accepted, supported, and not judged. They knew therapy would not have been successful, and they did not think they would have tried therapy again if the therapist had been judgmental or tried to extinguish their sexual interests. Conclusion The case of Doug and Christa illustrates some of the core issues and complications when assessing and intervening with paraphilia and Paraphilic Disorders. When cases involve sexual kink, it often feels like it is not just couples in the room; it is also societal and cultural values. One of the most important things to remember is that the medical, psychological, and judiciary systems have tended to pathologize consensual paraphilia when there is no research to support this. Consensual kinky sex is not only a healthy type of sexuality; when done well it actually reinforces healthy couple patterns such as honesty, open communication, and emotional and sexual attunement. Kinky sex in long-term relationship helps keep sexual excitement and passion in the relationship and may make it more likely that long-term couples experience the feeling of being in love across the lifespan of their relationship. Nevertheless, paraphilia can become harmful when they are non-consensual or when they create significant distress and impairment in an individual’s and couple’s life. It is important to discern whether this is due to the intensity and pervasiveness of the paraphilia, which is interfering in typical functioning, or if it is the incongruence between personal, couple, family, or societal values and the sexual interests that are causing distress. Different treatment approaches might be taken based on whether the case fits the former or latter characteristics (or both). References American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

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Nichols, M. (2014). Couples and kinky sexuality: The need for a new therapeutic approach. In T. Nelson  & H. Winawer (Eds.), Critical topics in family therapy: AFTA monograph series highlights. New York, NY: Springer. Nichols, M., & Fedor, J. P. (2017). Treating sexual problems in clients who practice “Kink”. In Z. D. Peterson (Ed.), The Wiley Handbook of sex therapy. Chichester, UK: John Wiley & Sons, Ltd. doi:10.1002/9781118510384.ch26 Page, K., Dermer, S. B., & Bachenberg, M. E. (2017). Sexual assessment and history taking. In J. C. Carlson & S. B. Dermer (Eds.), The Sage encyclopedia of marriage, family, and couples counseling. Thousand Oaks, CA: Sage. Perel, E. (2014). Erotic fantasy reconsidered: From tragedy to triumph. In T. Nelson & H. Winawer (Eds.), Critical topics in family therapy: AFTA monograph series highlights. New York, NY: Springer. Wismeijer, A. A. J., & van Assen, M. A. L. M. (2013). Psychological characteristics of BDSM practitioners. The Journal of Sexual Medicine, 10, 1943–1952. doi:10.1111/ jsm.12192

13 THE ALCOHOL AND DRUG ADDICTED COUPLE Michael R. Lloyd and Ellen Thursby

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ddiction has been historically viewed as an individual disease (Ruff, McComb, Coker, & Sprenkle, 2010; Klosterman & O’Farrell, 2013). Yet, individuals with substance use disorders are parts of families and are often in a relationship with a partner who may or may not be substance using. The impact of a substance use disorder on a couple can negatively impact their relationship in various ways. Due to the individual nature of a substance use disorder diagnosis, the non-using partner is often brought into the treatment process to “assist” the using partner. This limited approach to treatment neglects consideration of the couple as a unit. The couple’s relationship both impacts and is impacted by the substance use disorder. This chapter presents an overview of the literature on couple’s treatment for substance use disorders, assessment and treatment approaches to working with couples, and cultural considerations. A case is provided for specific context into the impact of a substance on a couple referred to treatment. Through the lens of this case, we present treatment recommendations for working with the specific couple that can be generalized for working with other couples impacted by substance use disorders. Overview of Research on the Substance Abusing Couple Substance use disorders impact couples and families—an estimated 9.4% percent (about 24.6  million individuals) over the age of 12 had used an illicit drug in the past month (Substance Abuse and Mental Health Services Administration, 2017). More than half of individuals above the age of 12 consume alcohol, with about 23% reporting binge drinking in the past month and 6.3% identified as heavy drinkers (Substance Abuse and Mental Health Services Administration, 2017).

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Research indicates that substance use is influenced by a constellation of individual, family, peer group, and community factors (Rowe, 2012). While treatment has historically focused on the individual, a growing body of evidence suggests that couples and family treatments are effective ways to treat substance abuse disorders (Rowe, 2012). These approaches recognize that individuals are relational beings, part of family systems with community connections. When the relationship becomes intolerable for one of the partners, couples may seek couple’s treatment. Aviram and Spitz (2003) note that couple’s treatment as a modality for substance use treatment is expanding. A growing body of literature identifies the social context and relationships of individuals with substance use disorders as important factors to consider in treatment. Regardless of whether both individuals in the relationship are substance using or not, the impact of substance use can negatively affect the relationship or alternately provide support toward recovery (Aviram & Spitz, 2003). Additionally, risk factors are identified that present a pressing need for couple’s treatment for substance use disorders, including domestic violence and child maltreatment. Substance use disorders are linked to serious family dysfunction, including poor psychosocial functioning of children, involvement in child welfare, and intimate partner violence (Rowe, 2012). Eight million children live in homes where at least one parent has a substance use disorder, placing these children at greater risk for maltreatment (ACF, Children’s Bureau, 2009). Of the children involved with Child Protective Services (CPS), between oneand two-thirds have a parent with a substance use disorder (ACF, Children’s Bureau, 2009). The impact of parental substance use on child development is well documented and places children at risk for cognitive delays, problems with self-control and behavior, a lack of social skills and positive peer relationships, and academic problems (Rowe, 2012; ACF, Children’s Bureau, 2009). Substance use is also linked to intimate partner violence (IPV) and has been shown to proceed IPV. Violence often occurs close to the time of consumption of the substance (Easton et al., 2007). While substance use disorders were initially seen as individual problems in need of individual treatment, research over the past 30 years focusing on partner and family treatment models point to better outcomes related to reduced substance use, improved partner relationships, and stronger family bonds (Klosterman & O’Farrell, 2013). Couples’ dysfunction and substance use are noted to be reciprocal causality, meaning that the substance use leads to relationship problems and relationship problems lead to substance use. Substance use and relationship problems reinforce each other, creating a cycle of unhealthy and dysfunctional patterns of relating (Klostermann, Kelley, Mignone, Pusateri, & Wills, 2011). Couples treatment for substance use leads to outcomes related to reduced substance use, improved partner relationships, and stronger family bonds

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(Klosterman & O’Farrell, 2013). Couples treatment for substance use disorders provides hope for the relationship and the individual with the substance use disorder. It is noteworthy that substance use may have distancing and functional qualities in relationships. For example, substance use may provide a way to tolerate emotions and serve to distance one partner from the other. Alternately, the conflict that results from this pattern of behavior may lead to closeness that is achieved through a make-up ritual (Aviram & Spitz, 2003). Morissette (2010) notes that when a couple seeks treatment, at least one individual in the partnership is deeply unhappy, and emotional intimacy is often impacted. Substance use may be used as a substitute for the lack of intimacy and the absence of affection in the relationship, and this pattern of relating becomes entrenched in the relationship. In a qualitative study, Simmons (2006) explores the relationships of ten polysubstance using couples. The couples expressed a commitment to the relationship and deep care for their partners, expressed in part through the collusion to acquire and use drugs (Simmons, 2006; Simmons  & Singer, 2006). The couples recognized that to stay sober, both must enter treatment and likely separate from each other during the initial counseling process. Fear about the relationship when partners were separated from one another during treatment influenced the likelihood each of entering and/or staying in treatment. Simmons and Singer found that therapist perceptions about the relationships also negatively impacted the treatment experiences of the couples as providers viewed the relationships as unhealthy and unstable. Simmons and Singer (2006, p. 5) note:

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espite often desperate daily struggles, all still aspired to the same social norms that most non-drug users aspire to in their relationships: love, fidelity, material and emotional support, and the ability to maintain a home.

Clearly, substance use disorders impact more than the individual. The use of couple’s treatment is an important modality with substance abusing couples. A  partner or family can serve as a motivator to seek treatment, and a healthy relationship and family dynamics can support the recovery of an individual. In turn, it is also possible for a partner to be a hindrance to recovery. In certain couples, the dynamic of the substance using partner is ingrained in the functioning of the couple, and therefore when the partner is sober this can create dysfunction and anxiety within the couple relationship. Assessment and Diagnosis When considering assessment for a couple when one or both partners has a substance use disorder, it is important to identify the individual issues of the

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partners, as well as the assessment of the couple as a unit. Assessment tools are available for brief screening or more detailed assessment. These tools are useful in assisting the therapist with diagnosing substance use disorders. For diagnostic purposes, the DSM 5 is a tool to assist the therapist with diagnosis. Substance use disorders are considered on an individual level and require the presence of various impairments of functioning in addition to the presence of tolerance and withdrawal. (American Psychiatric Association, 2013). Individuals with a substance use disorder are characterized by marked impairment across many domains of their lives. The person often wishes to cease or reduce intake of said substance, with little success. The phenomenon of craving exists, as well as growing tolerance toward the substance. Tolerance causes the person to take increasing amounts of the substance to feel the effects. More is necessary, yet often never enough. In addition to craving and tolerance, physical and/or mental withdrawal symptoms present themselves at the cessation of use. These symptoms can be minor, such as anxiety, difficulties sleeping, or mild depressive symptoms. They also can be life-threatening in the form of severe physical symptoms such as seizures or cardiac events. Those with substance abuse disorders are negatively impacted in many dimensions, including: work, family, and school or recreational obligations. The inability to fulfill a person’s obligations leads to significant personal, social, and emotional impairment. A  person may miss  work, family outings, or events, and be isolated from their friends and loved ones. Increased physical risk to themselves and others due to their substance use, as well as persistent use despite negative physical and mental health concerns, can also be considered when diagnosing a substance use disorder. This can occur by using substances in risky situations, such as while driving, as well as continued use despite physical and mental illness. These concerns need not all be present, but the more symptoms present, the more severe the substance use disorder (American Psychiatric Association, 2013). Treatment Approaches A growing body of literature points to the effectiveness of couple’s treatment as a modality for substance abuse treatment (Li, Armstrong, Chaim, Kelly, & Shenfeld, 2007; Klostermann  & O’Farrell, 2013; Rowe, 2012). When partners are involved in the treatment process, several benefits have been identified, including motivating the substance using partner to enter treatment, reducing the substance use, improved relationships, and increased treatment retention (Li et al., 2007). Couples and family treatment approaches focus on the dyad and avoid blaming the partner or family for the substance use (Simmons & Singer, 2006). Klostermann and O’Farrell (2013) identify three theoretical approaches to family treatment of substance use disorders: the family disease approach,

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family systems perspectives, and behavioral approaches. In the family disease approach, substance abuse is viewed as a disease of the entire family, not just the individual with the substance use disorder. From this approach, concepts of codependency and enabling emerged. Each member of the family seeks treatment for the substance use disorder, often Alcoholics Anonymous (AA) or Narcotics Anonymous (NA) for the substance uses and Al-Anon for nonusers (Klostermann & O’Farrell, 2013) A family systems perspective views substance use as organizing patterns of family interactions. The role of the therapist is to understand the importance of substance use in the interactional patterns of the family and promote healthier interactions that reduce or eliminate substance use (Klostermann & O’Farrell, 2013). Because the family disease model and family systems frameworks can easily be utilized and integrated with Behavioral Couples Therapy (BCT), BCT will be discussed at length in this section. Behavioral Couples Therapy (BCT) was developed in the 1980s at the Harvard Counseling for Alcoholics Marriages Project (Ruff et al., 2010). BCT “assumes distressed couples have low rates of rewarding interactions and high rates of punishing interactions, frequent negative interactions, and deficits in communication and conflict resolution” (Klostermann  & Fals-Stewart, 2008, p.  81). BCT recognizes that couples can support abstinence and that a reduction in marital conflict supports sobriety. BCT has two primary objectives: eliminate problemproducing substance use by utilizing the relationship to foster change and alter couple and family relationship patterns to support long-term abstinence (Klostermann et al., 2011). Four concepts guide BCT: couple engagement, supporting abstinence, relational focus, and a continuing recovery plan. BCT recognizes that the impact of substance use goes beyond the individual, and treatment needs to include the partner. The non-substance using partner is engaged in the treatment process, with consent of both partners. Both partners commit to treatment and to the relationship during the engagement phase. In the supporting abstinence phase, both partners dedicate themselves to maintaining sobriety with daily contracts. Included in this phase are trust discussions where the substance using partner commits to sobriety and the other partner provides support (Ruff et al., 2010). An important agreement made by the couple is avoidance of discussing past substance use or fear of future substance use in order to avoid sparking an argument that could lead to relapse (Klostermann & Fals-Stewart, 2008). BCT also focuses on the relationship, and the therapist teaches effective listening, problem-solving skills, and conflict resolution (Ruff et al., 2010). Through the use of homework, the dyad is given tasks that enhance the relationship. Couples focus on increased positive activities, sharing positive feedback about positive behaviors, and skill development related to discussing substance use and relapse prevention (McCrady et  al., 2016).

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Additional techniques used in this stage include catch your partner doing something nice, caring day, and shared activities (Klostermann et al., 2011) These techniques help the couple focus on the positive, promote active engagement in the relationship, and shift the focus of the interaction away from substance use. In the final stage, continuing recovery, the therapist helps the couple develop a plan to maintain sobriety, anticipate barriers, and identify how to manage relapse (Ruff et al., 2010). This written plan includes continued participation in AA meeting, daily trust talks, and contingency plans for relapse (Klostermann et al., 2011). Cultural Considerations Race, ethnicity, gender, sexual orientation, and class play important roles in substance use and the importance of intimate relationships. Simmons (2006) notes that discrimination based on race and ethnicity limit educational and employment options for the individuals in her sample. Additionally, participant involvement with the child welfare and criminal justice systems stymied their efforts to engage fully in society based on substance use and increased the likelihood of continued substance use through dealing and easy access to drugs. Treatment options may be limited for low-income clients. Simmons (2006) found that the two options available were either based on religion or the belief that substance use was the result of a personal or moral failing in need of punishment. These treatment approaches dissuaded engagement in treatment and resulted in the use of detox, followed by failure to maintain sobriety, leading to increased self-blame. Klosterman and O’Farrell (2013) note that empirical research to support the use of couples or family treatment models for substance use disorders is largely limited to white male patients with substance use disorders. The efficacy of couples treatment when the woman is diagnosed with the substance use disorder is more limited, although the evidence suggests effectiveness. Even more limited are studies related to same sex couples, non-white couples, and lower socioeconomic (SES) couples. The use of BCT for lesbian couples lacks systemic examination (Klostermann et al., 2011), despite multiple studies that indicate higher drug and alcohol use among LGBT women. The use of couple’s treatment for substance use disorders requires that clinicians make cultural and ethical considerations, including the definition of a family and who makes this determination; determining progress; and risks and benefits for each partner (Klosterman & O’Farrell, 2013). Broadening understanding and acceptance of client-defined relationships widens treatment options and, in light of existing empirical research on couples treatment, may lead to more successful outcomes.

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Case Example: Jennifer and Carol The following case illustrates an example of couple, Jennifer and Carol, who were impacted by an Alcohol Use Disorder. Assessment and Case Conceptualization Initial referral of the couple came through their primary care physician. Carol had been admitted to the hospital for dehydration. Tests showed elevated liver enzymes and other medical conditions that could be caused by excessive alcohol consumption. Carol strongly denied that she abused alcohol during her hospitalization and refused to meet with any mental health professionals during her admission. Upon release, Carol had a follow-up appointment with her primary care physician. Jennifer, her wife, came with her to the appointment. During the appointment, Carol told her physician, “You know, I have been drinking too much for years, and I’m think I’m finally ready to get help.” Jennifer was in the room during this conversation and, according to the referral, began crying and stated, “finally, we can get help, I was ready to leave her.” Carol was deemed an appropriate candidate for intensive outpatient treatment, or partial hospitalization, to allow her specialized, acute substance use treatment, yet she refused these referrals. Her doctor assessed that due to her recent hospitalization where she did not drink, she was not at current risk of life-threatening withdrawal symptoms. With their doctor’s strong recommendation, Jennifer and Carol agreed that couple therapy was a good place to start the treatment process. Jennifer and Carol came to couple therapy for their first appointment and individual assessments were initially performed on each of them separately. After these assessments were completed, the therapist met with the couple and completed a couples assessment, focusing on current functioning and relational health. The following information is taken from these initial assessments and is relevant for the treatment of Jennifer and Carol. Jennifer and Carol have been together for 12 years. Jennifer is a 43-yearold, Caucasian, cisgender (i.e., an individual whose personal and gender identity correspond to the sex he/she was assigned at birth) woman. Jennifer identifies her sexual orientation as lesbian. Jennifer was born in the Midwest into a middle-class family; her mother died when she was 13 years old from liver cancer. Three years after her mother’s death, her father remarried a woman with whom he worked. Jennifer described her relationship with her father as “amazing, we have been through so much, and he is always there to support me.” Jennifer does not drink alcohol due to her mother’s health history. She has lived her adult life “out of the closet, very out” and has been in “about three” serious relationships with women; she described Carol as “the one.” Jennifer described the state of her relationship as “difficult.” She reported that she loves Carol very much and the children do as well, but the

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Carol she married is very different from the current Carol. Jennifer stated: “We never even talk anymore, mostly we just text about the kids. It’s like she doesn’t even exist sometimes.” Jennifer described the status of her mental health as “failing.” When asked for clarification, Jennifer reported that she is anxious about Carol’s health and this is impacting her sleep and eating. Jennifer has been in individual therapy on and off and reported satisfaction with therapy in general. Carol is a 44-year-old, African American, cisgender woman. Carol identified her sexual orientation as “well, I married a woman, so what do you think?” Carol was also born in the Midwest to an upper-middle class family. Carol stated her childhood was “normal, nothing special.” When asked about her relationship with her parents, Carol stated, “I love my parents, it was not always easy for them.” When asked follow-up questions on why things were difficult for her parents, Carol was not forthcoming. Jennifer stated in her assessment that Carol’s father was a “bad alcoholic,” yet Carol did not offer this information during the assessment process. Carol and Jennifer have been married for five years and have two children. One child, Brad (age 14), is from Carol’s first relationship, and they have a child together, Samantha (age 4). Jennifer works full-time as a teacher and Carol stays home with Samantha before and after school, working part-time as a medical biller. Carol had never been in therapy, yet she did not report any resistance to the idea of therapy at the time of assessment. Diagnosis Individually, it is appropriate to diagnose Carol with an Alcohol Use Disorder. Regarding her drinking, Carol reported in her initial assessment that she used to drink “once a week” but now drinks every night, a “couple glasses of wine.” She stated that it is “hard to not have some wine to relax.” Carol reported that she used to work full-time as a medical biller, but “mornings were too rough, so I moved to part-time.” Further assessment revealed that mornings were rough due to consistent hangovers. Carol spends little time with Jennifer and their children and has been sleeping in the basement bedroom for the past year. Carol has been struggling with various health issues, mostly due to increased stress on her liver and heart: “my doctor says my drinking is making me sick.” Carol also reported “feeling shaky” when she does not drink every day. The preceding self-report from Carol led the therapist to conclude that she met the criteria for a DSM 5 diagnosis of Alcohol Use Disorder. Carol showed marked impairment across many domains of her life. She craves alcohol, and by reporting she needs to drink daily to avoid “feeling shaky” shows tolerance toward alcohol. Carol is experiencing adverse physical symptoms due to her alcohol use, as evidenced by her liver issues. She is experiencing

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negative impacts on the dimensions of her life, as evidenced by her cutting down on her work schedule and isolating herself in the basement from her family and friends. Carol also reported an increase in alcohol use to stave off physical symptoms (American Psychiatric Association, 2013). The diagnosis of Alcohol Use Disorder for Carol is important treatment information. It is also possible that Jennifer is suffering from a depressive disorder, yet the therapist concluded that further assessment was required for this diagnosis. The individual concerns of the clients impact their relationship, yet the purpose of this therapeutic experience is to address the issues the couple is having as a unit. As a couple, Carol and Jennifer have communication issues, conflict, and intimacy problems. Carol uses alcohol to isolate from her partner and the family as a way to manage her emotions and anxiety. As stated in the literature (Klosterman  & O’Farrell, 2013; Rowe, 2012), couple therapy where one partner has a substance use disorder focuses on ways to treat the substance use and problems in the relationship. Safe reduction or cessation of substances is crucial to the health of the relationship. Given the reciprocal causality (Klosterman  & O’Farrell, 2013), treatment focuses on both the substance use and the relationship. The couple’s assessment during the first session identified many concerns in the relationship. The primary issue the therapist identified related to the relationship dynamics of the couple. Both Jennifer and Carol stated in their individual and couple’s assessment that they loved each other, using that exact word. The main observable dynamic during the couple’s assessment was a lack of communication and a poor empathic connection. From the beginning of the session, both Carol and Jennifer interrupted each other consistently. The therapist concluded that this was evidence of lack of communication skills. Multiple attempts to set “ground rules” for the couple regarding basic communication in session, such as the use of “I” statements and allowing each to speak without interrupting the other, were often ignored. It was clear from this initial assessment that these communication patterns were deeply rooted in the relationship. The therapist also observed non-verbal cues that suggested a lack of empathy between partners. Often when Jennifer spoke, Carol would look at the therapist and roll her eyes. She would also make a noise best described as a grunt and look at the therapist. The therapist understood this behavior as an attempt at triangulation in order to form an alliance with the therapist against Jennifer. This relational pattern was examined related to Carol’s family of origin. Jennifer’s body language was quite closed off, as evidenced by her sitting as far to one side of the couch as possible during the session, with her legs and arms crossed tightly. The other non-verbal communication observed was a lack of eye contact by Jennifer when speaking to Carol. This lack of eye contact was not observed when Jennifer spoke to the therapist during the session.

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Case Specific Cultural Considerations The assessment identifies specific cultural considerations for the therapist to consider. The sexual orientation of the couple is identified as lesbian. They are also an interracial couple with children. These intersecting identities must be considered during the treatment process. Ricks (2012) identifies systematic heterosexism, defined by “societal-level ideologies and patterns of institutionalized oppression of non-heterosexual people” (p. 38), as one of the key forces contributing to alcohol abuse and misuse in the lesbian community. Shame and discrimination are also factors that can contribute to increased alcohol use among lesbians. Ricks (2012) also notes that in various studies lesbians presented with greater stressors and more severe alcohol use symptoms than their heterosexual counterparts. The assessment process did not uncover overt concerns about sexual orientation identified by either Jennifer or Carol, yet the culturally competent therapist must consider heterosexism, shame, or other factors that uniquely impact the lesbian client. Treatment Goals During the first session after assessment was completed, Jennifer and Carol were asked to identify their treatment goals. From a cognitive–behavioral perspective (CBT), the first step in treatment after the initial assessment is to collaborate with the couple in setting goals for therapy. The therapist told the couple that goals are better set by the clients, with the unit of treatment being the couple itself. Despite this guidance, Jennifer stated her main treatment goal was to “stop Carol’s drinking.” Carol visibly bristled at this, and the therapist asked Jennifer to reframe that goal in relation to the couple as the unit of treatment. Jennifer struggled with this, so the therapist asked Carol to identify a goal for treatment, Carol stated, “well Doctor Cooper says I have to stop drinking and obviously Jenn thinks I’m a drunk, so I guess I can’t drink.” The session ended at this point and a follow-up session was scheduled for the next week. The couple arrived for the next session as scheduled and the therapist began the session with a brief check-in. Carol stated, “I  have not drunk a drop of alcohol all week.” This statement was best described as defiant. Carol looked directly as Jennifer as if daring her to respond. Jennifer stated, “I’m glad she’s sober.” Following the check in, the therapist asked the couple to continue with the goal setting that was cut short from the previous session. It was clear that Jennifer and Carol had spent some time thinking about this, and their goals were much more focused on themselves as a couple and less on Carol and her drinking. Jennifer stated, “We want to be able to sleep in the same room together again.” The therapist asked what was stopping this from occurring in the present, and they both stated in unison, “we fight too much.” They laughed after that, and the therapist noticed a marked change in their verbal and non-verbal communication,

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with Carol even playfully hitting Jennifer when they spoke. The therapist asked the couple if the goal would be better stated as, “we want to learn how to communicate better so our relationship is more positive.” They both smiled and affirmed this goal. When asked about a second goal, Carol said, “I need help keeping away from the alcohol.” The therapist told Carol that her honesty was appreciated. Discussion followed about how Carol was attending Alcoholics Anonymous meetings and had obtained a sponsor. The therapist affirmed these choices and asked Carol how Jennifer could be helpful in maintaining abstinence from alcohol. Carol stated, “we could do things together again, it has been so long.” The therapist asked Jennifer for her feedback on this goal, and Jennifer affirmed this goal: “my whole purpose in therapy is to fix this, and we used to be so close.” The therapist took Carol’s initial goal, abstaining from alcohol, and expanded it from the individual and onto the couple. The therapist believed that increased, positive communication as well as increased activity together would allow the couple to move forward in a positive direction. Therefore, the two treatment goals are: 1.  Increase positive communication to foster stronger relational connections. 2. Increase couple-centered activities to reduce isolation and assist Carol with alcohol abstinence. Following the setting of goals, weekly sessions were recommended for Jennifer and Carol. The concluding section of this chapter focuses on treatment considerations as the couple moves forward. Treatment Considerations and Recommendations Jennifer and Carol identified goals to strengthen their relationship. We recommend considering the concepts of Behavioral Couples Therapy (BCT) to frame the therapeutic intervention with the couple. The four concepts of BCT are couple engagement, supporting abstinence, relational focus, and a continuing recovery plan (Ruff et al., 2010). Couple Engagement It is important in any therapeutic relationship to consider engagement as the primary phase of treatment. Engaging Jennifer and Carol in the treatment process will obviously be crucial to proceed with the change process. The therapist gained valuable insight during the assessment of the couple. Both Carol and Jennifer attempted to connect with the therapist in order to gain their support regarding each other’s behaviors. It is a common occurrence in couple therapy, yet necessary to identify the specific risks in this specific couple.

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Carol’s Alcohol Use Disorder was the precipitating event to begin therapy, and early in the assessment she made statements such as “well Doctor Cooper says I  have to stop drinking and obviously Jenn thinks I’m a drunk, so I guess I can’t drink.” Jennifer also stated that her goal was to “stop Carol’s drinking.” These statements are warning signs for the therapist that the potential for “ganging up on” Carol is a strong reality. Carol identified that both her doctor and Jennifer want her to stop drinking; later she stated that she wanted to be sober as well. The therapist must constantly assess for Carol’s desire for alcohol cessation and not risk assuming Carol has a strong desire for sobriety. She may, but this constant assessment is necessary so that communication lines stay open and Carol can form a strong therapeutic alliance with the therapist. The therapist must also be aware of engaging Jennifer consistently in the treatment process. As mentioned throughout this chapter, Alcohol Use Disorder is an individual diagnosis that negatively impacts the couple. Carol is the partner in the dyad with the substance use diagnosis; therefore, there can be a risk that treatment becomes “all about Carol.” The therapist must consistently engage both partners, remember that Jennifer is an equal member of the therapeutic intervention, and focus treatment on substance abstinence and improved couple functioning. Engaging the non-substance using partner in supporting alcohol abstinence is important for the relationship and relapse prevention. As the couple progresses, developing a plan for relapse prevention is important, so the couple knows what to do and supports to contact, including the therapist. Relapse is often a viewed as a normal occurrence in the recovery process, and it will be important for the therapist to convey this to Carol and Jennifer so that they can provide each other with support through the recovery process. Recovery should be viewed not just as a “Carol” issue but also as a couple and family issue. With a supportive relationship and fewer triggers, couples treatment provides processes that limit relapse. Hopefully Carol will not relapse, yet it is important to remember Jennifer is an equal member of the couple and that the couple is the unit of treatment. Supporting Abstinence Alcohol Use Disorder affects every dimension of a person’s life. Carol has stated she wants to be sober. It is imperative that the therapist identify risks to relapse. As stated previously, both Jennifer and Carol need to be included in this process. Carol has her Alcoholics Anonymous meetings and sponsor to assist her with personal abstinence. It is important that the therapist differentiate between that support and the goals of the couple’s treatment. Carol and Jennifer identified increasing couple-centered activities to reduce isolation and assist Carol with abstinence as their second treatment goal. This

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goal gives the therapist vital information into one of Carol’s main relapse triggers—isolation. The therapist can support Carol’s abstinence and at the same time work on the couple’s identified second treatment goal by focusing on couple-centered activities. The authors recommend spending a session focusing on couple interests, as this can be a very valuable part of couple treatment. Ask question of the couple, “what do you enjoy doing?” Often when one member of the couple has been abusing substances, this question can be difficult to answer, as most activities for the recent past have been in pursuit of or using alcohol. Morissette (2010) refers to the concept of relationship insulation (distancing from substance using friends and influences). This is crucial for the health of Carol individually and the health of the couple collectively. We recommend spending time in the session focusing on “what DID you enjoy doing in the PAST?” This exercise can bring the couple back to times before the substance use hijacked the relationship. When activities are identified, setting specific times and days to engage in the activities can be a useful tool to initiate more positive interactions between the couple. Relational Focus Jennifer and Carol identified their first treatment goal as increasing positive communication to foster stronger relational connections. This goal directs the focus of the therapist to the relationship. In order to foster stronger relational connections, basic relational dynamics and communication must be observed, analyzed, and if necessary, changed. Ruff et al. (2010), when discussing BCT, suggest that the role of the therapist is to teach effective listening, problem-solving skills, and conflict resolution. We agree with this approach and have suggestions specific to Carol and Jennifer. During the assessment, the non-verbal communication between Carol and Jennifer was not ideal. Jennifer struggled with making and maintaining eye contact with Carol. Carol would make frustrated noises and roll her eyes when Jennifer spoke. Both women struggled with allowing the other to speak uninterrupted. One way to address this in therapy would be through the use of identification and healthy mirroring. The therapist will need to identify unhealthy communication when it occurs in session. The therapist also can mirror positive communication by asking the couple to identify the differences between their unhealthy verbal and non-verbal communications, and those healthy communication patterns between the therapist and the couple. Another area to address is conflict resolution. Conflict obviously stresses a relationship, and when alcohol abuse is a part of the relational experience, conflict has increased risk. At no point in the assessment did either Carol or Jennifer identify physical conflict as a part of the relationship, yet verbal conflict was common. It will be critical to identify appropriate anger

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management and conflict resolution techniques in order to allow the couple to move forward in an empathic, healthy manner. Continuing Recovery Plan The continuing recovery plan for Jennifer and Carol is best evaluated by returning to their goals. The couple identified the two primary goals for treatment. This does not mean that these are the only goals that will arise. Flexibility in the treatment process is critical for success. Carol may relapse; she also may maintain abstinence. Jennifer may find that the reality of Carol being sober is much different than the wish for Carol to be sober. We have found in our work with couples that once the disordered couple begins to heal, underlying issues come to the surface. These issues often are the catalyst for the initial maladaptive functioning. Flexibility in the treatment process is critical. The authors recommend revisiting treatment goals every 90 days formally. This does not preclude adjusting goals on a session by session basis should crises arise, but a formal process to evaluate the recovery of the couple is advised. It is also advisable to have a discharge plan in place starting from the first session. Other supports must be identified should treatment end abruptly. The authors saw couples many times where substance use disorder was the primary concern for treatment. Once one or both partners achieved sobriety, usually on or around the 30-day mark, the couple would not return for treatment. This can happen regardless in spite of good engagement, assessment, and planning. Understanding the potential for this outcome and ensuring that other supports are in place will be important for the continued health and well-being of the couple. Supports such as Alcoholics Anonymous for Carol and Al-Anon for Jennifer are self-help/mutual aid groups that can help each partner navigate the Alcohol Use Disorder. Other supports such as friends, clergy, family, etc. are important to identify early in the therapeutic process to assist the clients with their continuing recovery. Whether or not the couple’s treatment is successful, it is imperative to assist the clients with additional supports for their individual and collective future health. Concluding Note The case of Carol and Jennifer illustrates key diagnostic criteria, assessment, cultural, and treatment considerations in working with a couple where one individual is using substances in unhealthy ways. The strengths of using a couple’s treatment approach in the treatment of what historically was seen as an individual problem are highlighted. The support of the non-substance using partner in entering and engaging in treatment, maintaining alcohol abstinence, and improving communication and the relationship are benefits identified in couple’s treatment for substance use. The substance using

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partner feels supported and is increasingly motivated to maintain alcohol abstinence as more positive interactional patterns are developed between the couple and in the family. The couple’s sessions focus on improving communication, reducing isolation, enhancing a positive relationship, and maintaining alcohol abstinence. Couples treatment for substance use addresses the reciprocal causality leading to sobriety and stronger, healthier family relationships. References Administration for Children and Families, Children’s Bureau. (2009). Strengthening families and communities: 2009 resource guide. Retrieved from https://www.child welfare.gov/pubpdfs/2009guide.pdf American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing. Aviram, R. B., & Spitz, H. I. (2003). Substance abuse couple therapy: Clinical considerations and relational themes. Journal of Family Psychotherapy, 14(3), 1–18. Easton, C., Mandel, D., Hunkele, K., Nich, C., Rounsaville, B., & Carroll, K. (2007). A cognitive behavioral therapy for alcohol-dependent domestic violence offenders: An integrated Substance Abuse–Domestic Violence Treatment Approach (SADV). The American Journal on Addictions, 16, 24–31. doi:10.20180115133145823875785 Klostermann, K.,  & Fals-Stewart, W. (2008). Behavioral couples therapy for substance abuse. Journal of Behavior Analysis of Offender and Victim: Treatment and Prevention, 1, 81–92. Klostermann, K., & O’Farrell, T. J. (2013). Treating substance abuse: Partner and family approaches. Social Work in Public Health, 28, 234–247. Klostermann, K., Kelley, M., Mignone, T., Pusateri, L., & Wills, K. (2011). Behavioral couples therapy for substance abusers: Where do we go from here? Substance Use and Misuse, 46, 1502–1509. Li, S., Armstrong, S., Chaim, G., Kelly, C., & Shenfeld, J. (2007). Group and individual couple treatment for substance abuse clients: A pilot study. The American Journal of Family Therapy, 35, 221–233. McCrady, B. S., Wilson, A. D., Munoz, R. E., Fink, B. C., Fokas, K., & Borders, A. (2016). Alcohol-focused behavioral couple therapy. Family Process, 55(3), 443– 459. doi:10.0180115134201290781617 Morissette, P. J. (2010). Couples at the crossroads: Substance abuse and intimate relationship deliberation. The Family Journal: Counseling and Therapy for Couples and Families, 18(2), 146–153. doi:10.201801041310491282607317 Ricks, J. (2012). Lesbians and alcohol abuse: Identifying factors for future research. Journal of Social Service Research, 38, 37–45. Rowe, C. (2012). Family therapy for drug abuse: Review and updates 2003–2010. Journal of Marital and Family Therapy, 38, 59–81. Ruff, S., McComb, J. L., Coker, C. J., & Sprenkle, D. H. (2010). Behavioral couples therapy for the treatment of substance abuse: A  substantive and methodological review of O’Farrell, Fals-Stewart, and colleagues’ program of research. Family Process, 49, 439–456. Simmons, J. (2006). The interplay between interpersonal dynamics, treatment barriers, and larger social forces: An exploratory study of drug-using couples in Hartford, CT. Substance Abuse Treatment, Prevention, and Policy, 1, 1–12.

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Simmons, J.,  & Singer, M. (2006). I  love you  .  .  . and heroin: Care and collusion among drug-using couples. Substance Abuse Treatment, Prevention, and Policy, 1(7), 1–13. Substance Abuse and Mental Health Services Administration. (2017). Key substance use and mental health indicators in the United States: Results from the 2016 National Survey on Drug Use and Health (HHS Publication No. SMA 17–5044, NSDUH Series H-52). Rockville, MD: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration. Retrieved from www.samhsa.gov/data/ 201801151339021864058733

14 THE SEXUALLY ADDICTED COUPLE Emily Petkus and Lisa Brown

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exual addiction is sexual behavior that is, in some way, out of control. While there is debate about what to call this type of behavior, one researcher suggests the use of “compulsive sexual behavior” until a more exact term is available (Cohn, 2014). Throughout this chapter, the terms sexual addiction, hypersexuality, and compulsive sexual behavior will be used to describe the subjective experiences of those who self-identify as sex addicts and the research that examines these behaviors. This chapter will provide an overview of sexual addiction and pornography followed by a representation of these issues in DSM-5 and the implications these issues have on couples’ relationships. Next, a case conceptualization will be used to explore the impact of sex and pornography addictions in couples and to offer assessment, treatment, and cultural considerations for couples dealing with these issues in counseling. Finally, a summary of treatment implications and recommendations will be offered. Overview: Sexual Addiction and Pornography Sexual addiction generally indicates excessive or uncontrolled sexual behavior. Sexual cognitions that lead to subjective distress, social or occupational impairment, and legal and financial consequences are additional markers for potential sexual addiction (Black, Kehrber, Flumerfelt, & Schlosser, 1997). Although sex addiction and pornography addiction are related, they can also be separate issues, as an individual who is addicted to sex usually acts out this addiction with others, while an individual who is addicted to pornography may compulsively view porn online or in other formats. There are a variety of behaviors that fall into the category of sex addiction: (1) multiple affairs; (2) excessive viewing of pornography; (3) online relationships;

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(4) use of sex workers; (5) masturbation with or without visual stimulation; or (6) frequent visiting of clubs where anonymous or recreational forms of sex are available (Cohn, 2014). Some research literature hypothesizes likely mechanisms of compulsive sexual behavior as a means for anxiety reduction and mood regulation, but these are based on clinical impression (Bancroft & Vukandinovic, 2004) and not empirical study. A key component to recognizing sex addiction is the destructive nature of the behavior and the loss of the power of choice. Warning signs identified by sexual addiction and compulsive sexual behavior literature define sexual behavior as: unexplained and regular time lapses (where the individual is engaging in compulsive sexual acts), lapses in efficiency at home and work, unpredictable mood changes, marked changes in sexual behavior, combinations of compulsive behaviors, and family history of addictive or compulsive behaviors. Some of these behaviors can be viewed as compulsive sexual rituals. Coping with stressors becomes even more difficult when not engaging in “compulsive” rituals relating to sex addiction. Sex addicts often struggle to recognize their anxious feelings and sources of stress. Additionally, ineffective and/or destructive relationship skills are another common challenge for clients with sexual addiction. Feelings of shame and isolation perpetuate the addictive and self-destructive cycles of sex addiction, and there is a self-reinforcing dopamine surge during sexual behaviors making biological models of addiction applicable as an explanation for these behaviors. Cohn (2014) suggests that addictive disease involves the following behaviors: (1) tolerance; (2) withdrawal; and (3) progressive, chronic, and sometimes fatal (Cohn, 2014). Those who identify as sex addicts have several common attributes: low opinion of and distorted beliefs about themselves, a desire to escape from unpleasant emotions, difficulty coping with stress, at least one powerful memory of a “high,” and an ability to deny having a problem (Earle & Crow, 1990). Many people who describe themselves as having compulsive sexual behavior also describe experiencing other compulsive behaviors (e.g., compulsive buying) (Black et al., 1997). Sexual addiction symptoms (similar to other addictions) include: a pattern of out of control behavior; severe consequences; inability to stop behavior despite consequences; an ongoing desire or effort to limit sexual behavior; use of sexual obsession and fantasy as a way to cope; increasing amounts of sexual experience (increased tolerance) because current level of activity is not sufficient; severe mood changes around sexual activity; inordinate amounts of time spent obtaining sex, being sexual, or recovering from sexual experiences; and neglect of important social, occupational, or recreational activities because of sexual behavior (Jones & Hertlein, 2012). One study conducted by Black et  al. (1997) found compulsive sexual behavior affected more men than women. Frequent comorbidity with anxiety disorders, depression, and alcohol and drug abuse/dependence were

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also apparent (Black et  al., 1997). Other comorbid issues included suicide attempts and childhood physical and/or sexual abuse. The average age at the start of compulsive sexual behavior was 18. At the time of this study, the frequency of comorbidity was excessive. Data from this study also suggested considerable overlap of disorders of impulse control, potentially indicating that some people may have a more general problem with impulsivity that is apparent in multiple areas. Due to the complexity and comorbidity of this behavior and lack of training, therapists often feel uncomfortable with the topic of sex addiction, which results in a failure to properly diagnose and treat it. Assessment and treatment of these issues will be addressed later in this chapter. Pornography Use of the Internet to fuel sexually based addictions further justifies the need to distinguish between addictions to the Internet and addictions on the Internet (Jones & Hertlein, 2012). Three key areas should be considered when examining Internet-based sexual addictions: (1) the amount of time spent online; (2) the times during the day that the involved partner is online; and (3) the content of the online activities (Jones & Hertlein, 2012). If curbing online activities is successful but a person is still seeking opportunities to be exposed to sexually explicit material elsewhere, the problem may be one of sexual addiction. The speed of information received and the potency of the information is crucial to fulfilling the need in sexual addiction (Jones & Hertlein, 2012). This can also be understood as addiction to the activity, not to the connection to other people and in the obsession to access sexual material online. Online sex addiction is defined by who or what is accessed online. Developing a tolerance, an inability to stop, irritability when trying to stop, engaging in sexual activity online for longer than originally planned, risk of losing a significant relationship or job, lying about use, or escaping difficult emotions are behavioral characteristics of people who are addicted to pornography. Rates of compulsive use of pornography have increased steadily for years (Zitzman & Butler, 2005). Patterns of compulsive use of pornography are being observed with increasing frequency given its ease of accessibility (and private use) online. The accompanying destructive effects on marital relationships as a result of compulsive pornography use is another observed pattern (Zitzman & Butler, 2005). Compulsive use of pornography parallels addiction in myriad ways. One example is seeking out sexual material on the Internet compulsively despite negative consequences. Another is failure to discontinue consuming pornography after negative consequences (e.g., relationship loss). One may also experience a growing dependence on sexual experiences to alter one’s state of conscious awareness as a (maladaptive) coping response for painful

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experiences. Each of these have negative implications in couples who seek treatment for concerns relating to pornography and sex addiction. Relationship Implications Sexual addiction and addiction to pornography have negative implications for individuals and couples. Sex addicts demonstrate secretive behavior to minimize their partner’s knowledge of the addiction. Additionally, addicts frequently engage in negative self-talk. Clinicians must understand the selftalk sex addicts practice, the secrets they keep, and the views of sex and intimacy they hold. The self-talk can often be traced back to core beliefs of “I am a bad and unworthy person,” “No one will love me as I am,” “my needs are never going to be met if I  must depend on others,” and “sex is my most important need” (Earle & Crow, 1990). Couple counselors can also help the non-addicted partner understand how these core beliefs impact the relational dynamic. Some literature highlights addicts’ symptoms of dissociation and depersonalization (Jones & Hertlein, 2012) as well as the addicts experiencing hypnotic-like trances during sexual fantasies (Earle & Crow, 1990). Feelings of losing time and disconnection from thoughts, feelings, and actions were common during sexually compulsive acts. In another study on spouses’ perceptions of treatment of sexual compulsivity during conjoint martial therapy, Zitzman and Butler (2005) hypothesized that relationship distress over pornography use is a result of a disruption of a secure attachment pattern. Attachment can be defined as the emotional bond one experiences in intimate relationships (e.g., parent–child, romantic partners). Earle and Crow (1990) suggests that the cycle of sex addiction involves the following phases: (1) stress or emotional pain; (2) acting out impulses; (3) shame and remorse; (4) promise of reform; (5) brief period of reform; and (6) acting out again, which is usually followed by depression, agitation, shame, and feelings of inadequacy and stupidity. This cycle is very painful for both the addict and those that love them. Another painful experience for couples struggling with sexual addiction is the distortion of the sexual experience. Participants with self-reported sexual addiction reported receiving negative messages about sexuality while growing up (Earle & Crow, 1990). Commonly reported sexual themes learned in childhood included (1) sex and sexuality are unspeakable; (2) sexual relationships are strained and stressful; (3) sex is evil/sinful; (4) all signs of sexuality should be hidden and are shameful; and (5) sex is secretive (if discovered, one would be forced to stop and lose one of the only feel-good aspects in one’s life) (Earle & Crow, 1990). Couples reported the following issues resulting from sexual addiction: loss of trust, high levels of anger, secrecy between partners, constraining communication, ego-centric or narcissistic attitudes, and a negative impact on sexual relationships between partners. Pornography is purposefully used

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to enable the detachment of sexual experiences from attachment dynamics in pair-bond relationships (Zitzman & Butler, 2005). To some partners, compulsive use of pornography is an “extramarital violation” that causes partners to doubt the security and safety in the relationship. This detachment of sexual behavior from a relational context becomes preferred. Developing more rewarding cycles, like improving self-esteem and relationship quality, need to be learned and reinforced within couples (Earle & Crow, 1990). DSM-5 Properly identifying online sexual behaviors has similar challenges to those of sexual addiction; both issues are not diagnosable disorders. The only behavioral addiction that is recognized in DSM 5 is gambling disorder (American Psychiatric Association, 2013). Problematic Internet use is only classified as a disorder under Internet gaming disorder in the DSM section for conditions for further study (American Psychiatric Association, 2013). While behavioral addiction might be a better fit for those who self-identify as having compulsive sexual behavior, it is lacking research to support its place in the DSM (Jones & Hertlein, 2012). Assessment Considerations Assessment of the sexually addicted couple is a multilayered process, as counselors must consider each individual within the dyad as well as the couple. This process begins with a thorough clinical intake evaluation. Essential to this assessment is gathering information regarding each individual’s sexual histories (Corley & Schneider, 2002; Edwards, 2012). A detailed psychological history evaluation must be conducted due to frequency of mental health comorbidity within the sexually addicted couple (Corley & Schneider, 2002; Edwards, 2012). As substance addition is highly comorbid with sexual addiction, an assessment of substance use is also necessary (Edwards, 2012; Kafka, 2010; Langstrom & Hanson, 2006). A medical history of both partners is warranted due to the high prevalence of sexually transmitted diseases among sex addicts, concerns of contracting HIV, and genital and/or urinary issues (Cooper  & Lebo, 2001; Hentsch-Cowles  & Brock, 2013; Kaplan  & Krueger, 2010). For both partners, family of origin and wellness issues across all areas of life should be ascertained (Edwards, 2012). Adverse family backgrounds (i.e., separation from parents during childhood) are correlated with frequent impersonal sexual practices (Langstrom & Hanson, 2006). Langstrom and Hanson (2006) define impersonal sex as sexual acts in which the focus lies with the act of sex itself, rather than with a sexual partner. This is a disruption of the courtship ritual in many cultures, which promotes emotional and physical closeness in romantic relationships. Other examples of impersonal sexual behaviors include masturbation, paying for sex, pornography use,

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multiple sex partners and/or changes in sexual partners, telephone sex, and cybersex. The goal of these sexual behaviors is to disconnect from interpersonal attachments requiring attentiveness and responsiveness to partners (Zitzman & Butler, 2005). Additionally, this study found men and women who engage in high rates of impersonal sex are more likely to experience physical and mental health issues compared to those engaging in high rates of sex within committed relationships (Langstrom  & Hanson, 2006). Impersonal sexual behaviors and sexual addiction were positively correlated with increased problems within current romantic relationships and negatively correlated with overall life dissatisfaction (Langstrom  & Hanson, 2006). The tendency for sex addicts to disconnect from their own emotions may play a role in dissatisfaction in relationships and life (Reid & Woolley, 2006). There are many connections between past history with trauma and sexual addictions. Many addicts report childhood physical and sexual abuse, especially for female addicts (Black et  al., 1997). Cooper and Lebo (2001) recommend assessing for physical abuse and early sexual abuse, including incest. Shame and anxiety created by childhood trauma is often sexualized in adulthood (Turner, 2009; Kaplan & Krueger, 2010). When trauma is present, trauma work should be prioritized in treatment. Case Conceptualizations: Individual and Couple Individual The Addicted Partner To determine the extent of the sexual addiction, an extensive sexual history evaluation must be conducted. It is common for sexual addicts to report the onset of high frequency and diverse sexual experiences during adolescence (Black et al., 1997; Langstrom & Hanson, 2006). Kaplan and Krueger (2010) recommend asking about the frequency and intensity of sexual interest, thoughts, fantasies, and behaviors. Frequency of sexual behaviors has also been used as a measurement of sexual health. Rather than pathologize high frequency of sex in every context (i.e., within committed relationships), counselors should consider high frequency of impersonal sexual behaviors when evaluating for sexual addiction. Specifically, counselors should assess the frequency and context of the following sexual behaviors: masturbation, pornography use, cybersex, telephone sex, frequenting strip clubs, and deviant sexual behaviors (Kaplan & Krueger, 2010; Edwards, 2012). Working within an addictions framework, the counselor will need to assess for tolerance and withdrawal as symptoms may occur for several days to months (Cooper & Lebo, 2001). Symptoms of sexual withdrawal can be extensive and include the following: fatigue, malnourishment, insomnia, rising anxiety, headaches, physical cravings, depressed mood, and feeling as

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though one is losing touch with reality (Cooper & Lebo, 2001). Pornography addiction withdrawal manifests as irritability, depression, anxiety, obsessive thoughts, and intense longing (Ford, Durtschi, & Franklin, 2012). Extensive research is available on the subject of comorbid disorders within the sex addicted population. Comorbidity between sexual addiction and other substance use disorders is well established (Black et al., 1997; Cooper & Lebo, 2001; Corley & Schneider, 2002; Bancroft & Vukandinovic, 2004; Langstrom & Hanson, 2006) and often associated with use of tobacco, excessive alcohol use, illicit drug use, and gambling addictions. Other common mental health diagnoses include Major Depression, Persistent Depressive Disorder, Anxiety, and Phobic Disorder (Black et al., 1997; Cooper & Lebo, 2001; Corley & Schneider, 2002; Bancroft & Vukandinovic, 2004). Screening for current or past suicide attempts should be conducted for those reporting a history of depression (Black et al., 1997). Notably, anxiety disorders have been found to be more highly correlated with pornography addiction as compared to sexual addiction (Short, Wetterneck, Bistricky, Shutter, & Chase, 2016). Personality disorders should also be considered, as comorbidity has been demonstrated with paranoid, histrionic, and obsessive compulsive personality disorders (Black et al., 1997; Langstrom & Hanson, 2006). While not true for every person with a sex addiction, the counselor should assess for paraphilic interests and behaviors. Multiple studies have confirmed the presence of paraphilic behavior in sexual addicts (Black et al., 1997; Langstrom & Hanson, 2006; Kafka, 2010). A paraphilia can be defined as non-genital sexual desires and behaviors equal to or exceeding interest in genital-focused sexuality (American Psychological Association, 2013). While Black et al. (1997), found the presence of paraphilic behaviors within their sample, this was true for only 3% of their sample. The behaviors reported within this study included exhibitionism, sadism, transvestic fetishism, fetishism, and telephone sex. Contrary to these findings, Langstrom and Hanson (2006) found a strong correlation between sexually addicted men and exhibitionism, voyeurism, masochism, and sadism. The Non-addicted Partner (Coaddict) The predominant treatment concern for the coaddict is Post-Traumatic Stress Disorder, as studies have confirmed the presence of PTSD symptomology in partners of sex addicted individuals (Corley & Schneider, 2002; Tripodi, 2006; Hentsch-Cowles  & Brock, 2013). Counselors should assess for codependency issues and understand how many coaddicts unknowingly contribute to the maintenance of the sexually addicted relationship (Hentsch-Cowles & Brock, 2013). Coaddicts’ emotional state and coping skills should be evaluated, as many may suffer from distrust, betrayal, isolation, anger, shame, violation, abandonment, and negative self-esteem (Bird, 2006; Reid & Woolley, 2006; Kaplan & Krueger, 2010). The discovery of sexual addiction can drastically change the

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coaddict’s worldview of the relationship, self, and one’s partner (Bergner & Bridges, 2002). Coaddicts report anger and confusion and question whether they should stay in the relationship (Bird, 2006). It is common for the coaddict to question whether they are respected and desired as well as the mutual commitment within the relationship (Bergner & Bridges, 2002). Coaddicts often assume they are no longer loved by the addict (Bergner & Bridges, 2002) and may attempt to prove this conclusion wrong through attempting to entice their partner sexually through makeovers, wearing lingerie, increasing the frequency of sex, and engaging in new sexual behaviors (Bird, 2006). This can introduce a new issue, as many coaddicts who continue to engage in sex with their partners report feeling like a sexual object (Bergner & Bridges, 2002), causing a negative view of one’s self. Not only do many coaddicts feel sexually undesirable, they may also experience feelings of worthlessness and/or that they have failed in their role as a partner (Bergner & Bridges, 2002). Due to the emotional distress, coaddicts may react by withdrawing, attacking, criticizing, clinging, or attempting to control the addict (Reid & Woolley, 2006). Couple When assessing relationship dynamics, counselors must be mindful of the variety of consequences of sexual addiction, including financial problems, occupational problems (losing job/promotions), and legal issues such as arrests (Short et al., 2016; Hagedorn, 2009). Short et al. (2016) found these problems are more pronounced for couples in which sexual addiction is the presenting issue as opposed to pornography addiction. Additional care should be exercised during the presence of sexually victimizing behaviors, and counselors should take action to directly address the problematic behavior to ensure the safety of those involved (Corley & Schneider, 2002). Couple therapy is contraindicated when there is ongoing sexual abuse and/or violence within the relationship. Cultural Considerations Couples should be encouraged to evaluate the impact their cultural background has on their sexual values, attitudes, behaviors, and overall sexual identities (Reid & Woolley, 2006; Edwards, 2012). The intersection of culture, sexual attitudes, and behaviors may be a focus of clinical treatment if there is inconsistency or conflict between ethical, spiritual, and/or moral beliefs and sexual behaviors (Edwards, 2012). For instance, masturbation is often associated with immaturity, sin, and mental illness, exacerbating feelings of shame and guilt. The couple will need to address their views on such behaviors to work towards integrating values and sexuality (Edwards, 2012). Conversations about sexuality may be strained as many cultures view sexuality as a private matter (Vogel, 2006/2007). Discussing sexual behaviors, fantasies, and urges in detail may present a challenge for many clients.

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Consideration should be given to the role of gender when working with sexual addiction. While not frequently researched, evidence has been found that sexual addiction does occur in women, with an estimated male to female prevalence ratio of 5:1 (Black et al., 1997; Langstrom & Hanson, 2006). As discussed earlier in the chapter, if a female partner is the sex addict, counselors should assess for a history of sexual abuse (Langstrom & Hanson, 2006), though males with sexual addictions may also have sexual abuse histories. Men may struggle to identify the presence of a sexual addiction, as societal expectations dictate men should be interested in engaging in sex that is frequent, diverse, and with multiple partners. Masturbating, pornography use, and attending strip clubs are accepted and even encouraged behaviors for men in society (Vogel, 2006/2007). Vogel (2006/2007) highlights these behaviors occur outside the context of a relationship and therefore lack intimacy and love. Treatment Considerations Assessment of the sex addict’s level and source of motivation is essential, as many do not find their addiction problematic (Kaplan & Krueger, 2010). Corley and Schneider (2002) warn possible goals of sex addicts may be maintaining the addiction, preventing separation from the coaddict, or easing guilt through divulging the nature of the sexual addiction—all of which can be counterproductive in treatment. Counselors should ascertain the addict’s conceptualization of the addiction as problematic, the desire to seek help for the addiction, and engagement in addictive behaviors (Corley & Schneider, 2002). In contrast, coaddicts’ goals may include gathering a comprehensive history of the sexual addiction, proving their suspicions, assessing their potential for contracting an STD, or having their partners stop the sexual addiction (Corley & Schneider, 2002). Some coaddicts become vengeful and attempt to gather information on their partner’s infidelity for the purpose of future retribution (Corley & Schneider, 2002). Other assessment areas include determining adverse impact of the addiction on the couple relationship, unsafe sexual behaviors, and any compulsive and/or controlling behaviors of the addict or his/her partner within the relationship (Hentsch-Cowles  & Brock, 2013). Due to the complex nature of sexual addiction and pornography use, multiple treatment modalities are recommended in addition to couple therapy. The most common modalities utilized are to support management of the addiction and often include a group 12-step program, individual relapse-prevention, and psychopharmacological treatment. Couple therapy will not be successful if the sex addict does not begin working to control the addiction. Without halting the addiction, any progress in couple therapy is forfeited (Bird, 2006).

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Treatment of sexual addiction poses a challenge that does not exist when treating substance addictions. If one is addicted to alcohol, the addict can work to avoid people, situations, and places that trigger alcohol use. However, a sex addict cannot avoid widespread triggers within an American culture that values sexuality (Hagedorn, 2009). In the early stages of managing sexual addiction, the counselor can work with the sex addict to address specific problem behaviors. One such management technique is to recommend safer sex practices (i.e., wearing condoms) to reduce the risk of contracting or spreading STIs. Restricting access to pornography by using programs to prevent access to sexual content on the Internet or moving computers to a common area within the home may assist in controlling pornography addiction (Ford et al., 2012). Holding sex addicts accountable for behaviors can be accomplished by keeping a log of sexual urges and encouraging changes in daily routines to maintain sobriety (Kaplan & Krueger, 2010). Counselors may recommend filling leisure time with activities such as sports, exercise, and hobbies and spending time with friends and family (Bird, 2006). To ensure a successful start to couples treatment with sexual addicts, counselors must begin by stressing the importance of honesty throughout the counseling process. As trust is a major aspect of recovery for the couple, addicts are encouraged to maintain honesty about sexual behaviors and infidelity (Corley & Schneider, 2002). A potential ethical dilemma can occur if honesty and disclosure are not addressed early in treatment. Consider a counselor who meets with the sexual addict on an individual basis to perform the initial assessment and learns the full extent of the sexual addiction. If the sex addict has not fully disclosed this history to the partner and the counselor maintains this secrecy, the counselor is now colluding with the sex addict. It is imperative for the sex-addicted couple to understand the counselor will not keep secrets for either individual. If secrecy is maintained, trust issues are exacerbated and lead to a halt in recovery (Corley & Schneider, 2002). Disclosure of the sexual or pornography addiction has extensive implications for the counseling process. There is a distinction in the way coaddicts respond to counseling based on their level of knowledge of the addiction. Coaddicts aware of the problematic sexual behaviors present with hopelessness and significant denial lasting for years (Tripodi, 2006). Many have engaged in stonewalling and degrading the addict to cope with feelings of futility after attempts to help the addict fail (Tripodi, 2006). These coaddicts tend to have insight into how their lack of confronting the sexual addiction has enabled the behavior to continue and are motivated to address their emotional pain (Tripodi, 2006). Coaddicts previously unaware of the sexual addiction may present in crisis (Tripodi, 2006). Shock, rage, anger, devastation, and hopelessness are common emotional reactions (Corley & Schneider, 2002). Prior to the disclosure of sexual addiction, many were suspicious that something was not right with

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their partner or in their relationship, yet many are afraid to confront these worries and oscillate between suspicion and denial (Tripodi, 2006). When confronted with evidence, coaddicts often engage in “detective behaviors,” in which they begin to actively seek information to confirm their suspicions (Milrad, 1999). For many, this becomes the point at which they seek couples counseling, as they must determine if the relationship should be maintained or terminated (Milrad, 1999). Regardless of the coaddict’s awareness of sexual addiction, counselors should be aware that sex addicts rarely disclose all information upfront in an attempt to soften the blow. The disclosure process is ongoing, as addicts may withhold information for fear of threats of separation or divorce (Bird, 2006) and feelings of shame. The addict may make several disclosures as all sexual behaviors may not be remembered or be thought to have relevance (Bird, 2006). This process is further complicated by the coaddict’s perceived “need to know.” Coaddicts may initially seek detailed accounts of or demand complete disclosure of sexual behaviors to validate their suspicions as a way to make sense of the past, validate suspicions, and regain control (Milrad, 1999). The information gathered is viewed as helpful in determining exposure to STIs and to evaluate the sex addict’s commitment to the relationship (Milrad, 1999). The counselor must work with both parties to navigate disclosure. While honesty is seen as crucial to the recovery process, counselors must take into account the wellness of the coaddict, as disclosures often lead to trauma reactions and symptoms of Post-Traumatic Stress Disorder. Careful monitoring of the coaddict’s ability to cope is necessary throughout the disclosure process (Corley & Schneider, 2002). Counselors can work with the sex addict to determine if full disclosure is appropriate (Corley & Schneider, 2002). The extent of the sexual behaviors may be helpful in determining the level of disclosure. For example, is the addict still engaging in the problematic behaviors? What is the extent of the lies told to the coaddict? What are possible positive and negative consequences of disclosure to self, partner, and relationship? Corley and Schneider (2002) highlight that the setting and timing of the disclosure are aspects worth careful consideration and should be taken into account throughout the counseling process. Case Example: Bruce and Chad Bruce, a 40-year-old Euro-American, and Chad, a 42-year-old African American male, have been together for four years and are seeking couples counseling for the first time. Bruce is a private tutor for wealthy families. They live in Washington, D.C. Bruce mostly identifies with his home state of Alabama and southern American culture. Chad is a history teacher at a private prep school and is from Baltimore.

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They have come to couple therapy because Chad discovered Bruce’s excessive use of pornography. Bruce acknowledges spending considerable amounts of time looking at porn. He reported trying to discontinue his pornography use many times by cutting off his Internet access and installing website blockers but states that he cannot stop. Chad admits to snooping on Bruce’s computer and finding multiple websites seeking anonymous sex with strangers. Chad confronted Bruce, who did not deny his actions. Bruce wants to stop and remain in his relationship with Chad but fears Chad will leave him. Assessment Considerations Assessment began with this couples’ relationship history, couple dynamics, and individual and joint sexual histories. Bruce reported pursuing Chad for six months after the conference where they met before they began dating. The couple has lived together for the last year and begun discussing marriage. Upon discovering Bruce’s interest in cybersex and pornography use, Chad has expressed doubts about marriage. The couple estimated engaging in sex approximately three to four times per week. Bruce initiates sex more frequently, and the couple reported experiencing conflict over preferred sexual acts. Chad reported feeling uncomfortable with some of Bruce’s requests. Both partners denied any difficulty with arousal, maintaining an erection, or achieving orgasm. Information on the role of pornography within their relationship was gathered. The couple reported watching pornography together for the purpose of mutual arousal. Bruce reported using pornography for the purpose of masturbation when Chad was unwilling to fulfill his sexual fantasies. Lastly, the couple was asked to articulate their level of commitment and goals for couples counseling. Bruce expressed remorse and embarrassment that his use of pornography and interest in cybersex has begun to interfere in his relationship with Chad. Bruce intended to discontinue his use of pornography to repair his relationship. Chad expressed doubt over Bruce’s commitment to counseling as he has struggled to control his pornography use in the past. Chad reported he was willing to participate in counseling but had doubts about their ability to repair their relationship. Bruce was asked to detail his frequency, intensity, and duration of pornography use and cybersex and stated that his use of pornography began during college as he began to identify as gay and felt unsafe coming out of the closet during this time. Bruce reported using pornography multiple times each day for the purpose of masturbation and stated that his needs were no longer being met by pornography, prompting him to seek cybersex. Assessment also included screening for other hypersexual behaviors: infidelity, telephone sex, prostitution, and attendance at strip clubs. Bruce

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denied currently engaging in these behaviors. Chad was also asked to detail his sexual history but reported that he had engaged in safe sex his entire life and has only had unprotected sex with men in which he was in a committed relationship. DSM-5 Bruce reports experiencing difficulty controlling his sexual behavior and pornography use after repeated attempts to stop. He also states that he has struggled with depression since he was an adolescent. Because of Bruce’s report of and his meeting specific criteria, he was diagnosed with other sexual dysfunction, not due to substance or known physiological condition (Krueger, 2016; American Psychiatric Association, 2013). Chad does not fully meet diagnostic criteria for any other DSM-5 disorder. It is important to consider a rule-out diagnosis of Post-Traumatic Stress Disorder (PTSD), as it is often seen in partners of sex addiction. He does report experiencing relationship distress with his intimate partner, which is a z-code diagnosis in the DSM-5. Case Conceptualizations: Individual and Couple Individual Case Conceptualizations Bruce disclosed it was especially difficult for him to be open about his sexuality in rural Alabama. He reported having a profound fondness for farm living but understands the culture of “typical” rural living is not accepting of the gay population. Bruce reported having a strong connection to his Christian faith and grew up with a single mother who was very rigid and controlling, due to the sudden death of his father when Bruce was 12. Bruce’s mother was critical of him and struggled to be supportive and accepting, especially when he came out as gay. As an only child, though he excelled in school and sports, he had few connections to other people. He reported these activities kept him busy and allowed him to connect to others (especially men) in ways that did not seem threatening. Bruce came out after graduating college. During this time, he found the opportunity to pursue sex with different men to be exciting. He enjoys the thrill he gets from finding men on hookup sites or meeting strangers in public places. This thrill is short-lived as he is consumed by regret after engaging in anonymous sex. Bruce reported a deep desire to be in a relationship, get married, and have children. The conflict he experiences between his values, desires, and sexual behaviors is very painful for him. Chad grew up in Baltimore in a two-parent, middle-class home and has a younger sister. He reported that his parents worked long hours, requiring him to care for his sister. As such, Chad has maintained a close relationship with his sister and parents. Chad denied any personal or family history of abuse, substance abuse, or mental illness. When Chad presented for his

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individual session, he was upset and reported feeling helpless because he felt a lack of control within his relationship. He stated that he was shocked by Bruce’s addiction, as they had been engaging in sex several times a week. He struggles to understand Bruce’s addiction but wants to try to make his relationship with Bruce work. Couple Case Conceptualization Chad feels betrayed, angry, and sad. He stated that he feels powerless in the face of Bruce’s addiction and at times feels like he is at fault for not giving Bruce what he needs. Bruce is remorseful about his actions yet deeply conflicted about his behavior because it feels good in the moment. He stated that he is struggling to get his addiction under control so he can focus on his relationship with Chad. Cultural Considerations The following dimensions of culture should be considered when working with any client or couple: race, gender identity and expression, religious affiliation, social class, age, and sexual orientation. Cultural considerations specific to Bruce and Chad include their different racial, geographic (north/ south, urban/rural), and social class and religious differences, as well as the differences in their experiences as gay men (e.g., coming out). Bruce was raised in a small, rural farming town with few opportunities to develop an identity as a gay man. Now that Bruce is living in D.C., he reports feeling like “a kid in a candy store” and finds it challenging to resist the excitement of meeting new men, which may be a factor contributing to his addiction. Treatment Considerations Couples treatment with this couple must stress the importance of honesty throughout the therapy process. Trust is a major aspect of recovery for the couple recovering from the pain of the sex addiction cycle and the betrayal experienced by the coaddict. In this case, Bruce will be encouraged to maintain honesty about his sexual behaviors and infidelity throughout the duration of treatment (Corley & Schneider, 2002). Bruce and Chad’s counselor should not keep secrets for either individual. Secrecy exacerbates the damaged trust and disrupt recovery (Corley & Schneider, 2002). Chad will likely engage in “detective behaviors” as he seeks information to confirm his suspicions (Milrad, 1999); therefore, relationship dynamics need to be repaired and trust restored. Unless the detective behaviors stop, Bruce will likely have difficulty feeling safe enough in his relationship with Chad or with his therapist to disclose the depth of how difficult it is for him to stop seeking anonymous sex with strangers and seeking access to sexually explicit material online.

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Conclusion Treating sex addiction in couples requires counselors to address complex issues for the individual struggling with the addiction and the couple. For the addict, treatment is a process that involves honesty, accountability, behavior change, and exploration of interpersonal and family-of-origin dynamics. The coaddict’s therapeutic process requires them to rebuild trust and relationship dynamics with their partner. Both partners must learn more adaptive ways to communicate their relationship needs while maintaining trust and accountability between them. Although sex addiction can have negative effects, it is possible to recover and have healthy, successful, and fulfilling relationships. References American Psychiatric Association. (2013). Diagnostic and statistical manual for mental Disorders (5th ed.). Arlington, VA: Author. Bancroft, J., & Vukandinovic, Z. (2004). Sexual addiction, sexual compulsivity, sexual impulsivity, or what? Toward a theoretical model. The Journal of Sex Research, 41(3), 225–234. Bergner, R. M.,  & Bridges, A. J. (2002). The significance of heavy pornography involvement for romantic partners: Research and clinical implications. Journal of Sex & Marital Therapy, 28, 193–206. Bird, M. H. (2006). Sexual addiction and marriage and family therapy: Facilitating individual and relationship healing through couple therapy. Journal of Marital and Family Therapy, 32(3), 297–311. Black, D. M., Kehrber, L. L. D, Flumerfelt, D. L., & Schlosser, S. S. (1997). Characteristics of 36 subjects reporting compulsive sexual behavior. The American Journal of Psychiatry, 154(2), 243–249. Cohn, R. (2014). Calming the tempest, bridging the gorge: Healing in couples ruptured by “sex addiction”. Sexual and Relationship Therapy, 29(1), 76–86. Cooper, M., & Lebo, R. A. (2001). Assessment and treatment of sexual compulsivity: A multi-modal perspective. Journal of Social Work Practice in the Addictions, 1(2), 61–73. Corley, M. D., & Schneider, J. P. (2002). Disclosing secrets: Guidelines for therapists working with sex addicts and coaddicts. Sexual Addiction  & Compulsivity, 9, 43–67. Earle, R. H., & Crow, G. M. (1990). Sexual addictions: Understanding and treating the phenomenon. Contemporary Family Therapy: An International Journal, 12(2), 89–104. Edwards, W. (2012). Applying a sexual health model to the assessment and treatment of internet sexual compulsivity. Sexual Addiction & Compulsivity, 19, 3–15. Ford, J. J., Durtschi, J. A., & Franklin, D. L. (2012). Structural therapy with a couple battling pornography addiction. The American Journal of Family Therapy, 40, 336–348. Hagedorn, W. B. (2009). Sexual addiction counseling competencies: Empiricallybased tools for preparing clinicians to recognize, assess, and treat sexual addiction. Sexual Addiction & Compulsivity, 19, 3–15.

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Hentsch-Cowles, G., & Brock, L. J. (2013). A systemic review of the literature on the role of the partner of the sex addict, treatment models, and a call for research for systems theory model in treating the partner. Sexual Addiction & Compulsivity, 20, 323–335. Jones, K.,  & Hertlein, K. (2012). Four key dimensions for distinguishing internet infidelity from internet and sex addiction: Concepts and clinical application. The American Journal of Family Therapy, 40(2), 115–125. Kafka, M. P. (2010). Hypersexual disorder: A proposed diagnosis for DSM-V. Archives of Sexual Behavior, 39, 377–400. Kaplan, M. S., & Krueger, R. B. (2010). Diagnosis, assessment, and treatment of hypersexuality. Journal of Sex Research, 47(2–3), 181–198. Krueger, R. (2016). Diagnosis of hypersexual or compulsive behavior can be made using ICD-10 and DSM-5 despite rejection of this diagnosis by the American Psychiatric Association. Society for the Study of Addiction, 111, 2107–2114. https://doi.org/10/1111/add.13366 Langstrom, N., & Hanson, R. K. (2006). High rates of sexual behavior in the general population: Correlates and predictors. Archives of Sexual Behavior, 35(1), 37–52. Milrad, R. (1999). Coaddictive recovery: Early recovery issues for spouses of sex addicts. Sexual Addiction & Compulsivity, 6, 125–136. Reid, R. C., & Woolley, S. R. (2006). Using emotionally focused therapy for couples to resolve attachment ruptures created by hypersexual behavior. Sexual Addiction & Compulsivity, 13, 219–239. Short, M. B., Wetterneck, C. T., Bistricky, S. L., Shutter, T., & Chase, T. E. (2016). Clinicians’ beliefs, observations, and treatment effectiveness regarding clients’ sexual addiction and internet pornography use. Community Mental Health Journal, 52, 1070–1081. Tripodi, C. (2006). Long term treatment of partners of sex addicts: A multi-phase approach. Sexual Addictions & Compulsivity, 13, 269–288. Turner, M. (2009). Uncovering and treating sex addiction in couples therapy. Journal of Family Psychotherapy, 20, 283–302. Vogel, J. E. (2006/2007). Using relational-cultural theory to conceptualize couple interventions in the treatment of sex addiction. Journal of Creativity in Mental Health, 2(4), 3–17. Zitzman, S. T., & Butler, M. H. (2005). Attachment, addiction and recovery: Conjoint marital therapy for recovery from a sexual addiction. Sexual Addiction & Compulsivity, 12, 311–337.

15 THE DISTRACTED COUPLE Larry Maucieri

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he residual adult phenomenon of Attention-Deficit/Hyperactivity Disorder (ADHD) is no longer in question. Most clinicians recognize ADHD as a problem of childhood or adolescence often involving school performance, but its symptoms persist well into adulthood for many individuals. Our lack of awareness about the role of ADHD in adults who struggle with work, relationships, and personal achievement results in an piecemeal therapeutic experience at best and an unproductive, mistaken, and ill-fitting treatment attempt at worst (Betchen, 2003). A Description and Overview of ADHD ADHD is a neuropsychiatric condition with symptoms of hyperactivity, impulsivity, and/or inattention. The predominantly inattentive type was previously called Attention Deficit Disorder (ADD) and, although that term is no longer in the DSM, ADD is a common shorthand for the inattentive form of ADHD. It is the most common form of adult ADHD. When individuals have significant symptoms of both inattention and hyperactivity/impulsivity, they have the combined type of ADHD. While a full diagnosis of adult ADHD does not always persist from childhood ADHD, many adults continue to be impacted by ADHD into their early, middle, and even late adulthood. Kessler et al. (2006) estimated that residual symptoms of ADHD might persist into adulthood for up to 4 or 5% of individuals who had the condition as children or adolescents. Thus, while ADHD is common in childhood and adolescence, it sometimes persists into adulthood. Symptoms of adult ADHD usually involve inattention, procrastination, impulsivity, and distractibility. Hyperactivity may be present, but it occurs less often in adults.

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Because ADHD is a neurodevelopmental disorder, it cannot first emerge in adulthood (American Psychiatric Association, 2013). Signs of ADHD must be present in childhood by reliable evidence or objective support. Some authors use the term secondary ADHD to describe ADHD-like symptoms due to concussions or other neurologic incidents, but these are not truly ADHD. They would instead be diagnosed as major or mild neurocognitive disorders in the DSM-5 (American Psychiatric Association, 2013). DSM-5 Diagnostic Conceptualization ADHD in the DSM-5 The primary current reference for clinical diagnosis among most mental health workers is the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Changes made in the DSM-5 criteria for ADHD from the DSM-IV-TR were not as sweeping as originally proposed. A few modifications were adopted. In DSM-5, the individual symptom criteria more clearly reflected the experiences and behaviors of adults, rather than just children and teens. The number of symptoms required for later adolescents and adults to meet diagnostic criteria was modestly reduced from six to five in the ADHD subcategories of inattention and/or hyperactivity/ impulsivity (American Psychiatric Association, 2013). Finally, the age of initial symptom onset was adjusted upward from about second grade to sixth grade (American Psychiatric Association, 2013). While ADHD is well established in the research and clinical literatures, it remains controversial due in part to its over-diagnosis. Some of these concerns stem from subpar clinical practices. Adherence to the DSM-5 criteria for ADHD is often lacking in many settings. A thorough consideration of evidence from multiple sources is not usually done. Numerous other causes for ADHD-like symptoms (e.g., head trauma, hypoglycemia) are not often explored. Finally, clinicians over rely on convenient but transparent selfreport scales and questionnaires. The presentation of ADHD in adults can sometimes be subtle, especially in individuals with higher intellect and cognitive reserve. Their symptoms tend to be less pronounced than in children. Additionally, ADHD often occurs with other conditions, such as depression, anxiety, OCD, tic disorders, and substance abuse. Accurate diagnosis of adult ADHD is challenging for even experienced clinicians. Recognition of ADHD in Adults As ADHD must begin in childhood, with adults one must retrospectively establish that at least some symptoms were present in multiple settings (e.g., home, school) by age 12. This solidifies the symptoms as part of a neurodevelopmental disorder and not something else.

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Whether data are obtained via interview or a questionnaire, we must concede that the information is subject to the accuracy and biases of childhood and adolescent recollections. In a more detailed psychological assessment, external confirmation might be available with collateral information from a knowledgeable other (e.g., sibling, parent). Still, the passage of time makes establishing the early symptoms challenging for adults with possible ADHD. For this reason, old report cards and school documents (when available) can be excellent sources of support for early problems that may be signs of ADHD. To establish childhood symptoms of ADHD, the clinician need not do a time-consuming investigation. The DSM-5 criteria do not require that the full criteria of ADHD be met by age 12; rather, just some signs of the condition should be seen by that age. When present in adults, ADHD usually manifests in the inattentive format. Typical symptoms include inattention, distraction, disorganization, and procrastination. Poor impulse control is also common (Young  & Amarasinghe, 2010), and in adulthood this might occur as reckless driving, hasty spending, substance abuse, or casual sexual encounters. Adults with ADHD often struggle at school or work and in their interpersonal relationships (Maucieri, 2013; Young & Amarasinghe, 2010). Couple Case Conceptualization Little scholarship has focused on couples treatments for ADHD until recently. ADHD was long considered an archetypal syndrome of childhood and adolescence. When it was recognized as a potential disorder in adulthood, its treatments mainly involved medication and directive forms of individual psychotherapy. These interventions can be effective, but there is an unfulfilled need for treatments adapted specifically to the relationships for these adults and their partners. Most adults seeking therapy for ADHD have been or are currently taking medication(s) for the condition. Without medication, many individuals with ADHD struggle to effectively manage their focus and distraction symptoms. The most common combination of treatments for ADHD involves medication and therapy. Medication is the first choice of treatment for adults with ADHD, but directive forms of individual psychotherapy (i.e., CBT) are also particularly useful for the management of adult ADHD symptoms (Young & Amarasinghe, 2010). Evidence-Based Treatments for ADHD Couple therapy is almost never attempted before medication and individual psychotherapy have been tried. Couples work also usually occurs concurrent with medication and/or psychotherapy. In the couples sessions, the problems within the relationship itself—rather than the individual—can be explored.

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ADHD often occurs with other conditions, so clinicians must be ready to address signs of depression, anxiety, substance abuse, and other challenges when working with these couples. Moreover, the genesis of certain symptoms should be explored and not assumed. For example, procrastination might result from distractibility and overstimulation in ADHD, but it might also reflect an avoidant coping style to manage anxiety. Clinicians should explore the roots and functional purposes of problematic behaviors, rather than assuming what they seem to be. Couples Focused Treatment for ADHD The clinical focus on ADHD in couple therapy is rather new. One area that comes up often in this milieu involves the negative social effects of ADHD. Social Deficits in ADHD While not explicitly recognized in the DSM-5, ADHD often involves deficits in social and interpersonal skills. Moreover, numerous symptoms of ADHD are likely to degrade the quality of a long-term relationship. These include poor focus, inattention to detail, unfinished projects, excessive talking, impatience, restlessness, and cutting others off in conversation. Initially seen as tolerable or quirky, they eventually erode the stability and quality of the relationship. In working with a couple impacted by ADHD, the clinician must recognize not only the negative effects of core ADHD symptoms on the relationship, but also the frequent social and interpersonal deficits as well. Bruner, Kuryluk, and Whitton (2015), for example, found lower levels of relationship satisfaction among college students who had the combined form of ADHD (significant symptoms of both inattention and hyperactivity/impulsivity) compared to those without ADHD. Men with inattentive ADHD were also more likely to begin dating later, have fewer relationships, and experience greater opposite-gender rejection relative to nonADHD male peers (Bruner et  al., 2015). Robbins (2005) also noted that adults with ADHD often presented with underdeveloped social and communication skills. The nature of ADHD may itself restrict the reading of important social cues, leaving individuals with ADHD to be ill-prepared and inept in social interactions. Roggli (2013) explained,

I

nattentive girls [with ADHD] are self-absorbed, lost in their own thoughts, and largely unaware of facial signals (and perhaps verbal signals, too). . . . Hyperactive/impulsive girls may be too busy talking to notice a small sigh or averted eyes, dismayed when their conversation ends abruptly. (p. 127)

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For peers of children and adults with ADHD, however, such behaviors are seen as conscious, immature, and annoying. Over time, the individual with ADHD may be rejected and shunned. Many children with ADHD grow into adults who have negative and awkward social experiences. Even if they fully accept their diagnosis of ADHD, at some level they usually agree with their peers that they are defective, problematic, or needy. Their self-esteem is degraded, and they experience shame from years of academic underachievement, lost or stalled jobs, and broken relationships. They sincerely want to do better, but just don’t know how. The Parent–Child Dynamic and ADHD The relational challenges and interpersonal sequelae of adult ADHD are front and center in the adult long-term relationship. A  common dynamic that emerges in couples impacted by ADHD is one of gradual compensation and counterbalance over time. While it seems like a good solution initially, it’s just a quick fix that never addresses the actual problem. Instead, the balance of power and responsibility end up tilting toward the non-ADHD partner, and both partners pay a steep price. The relationship putatively begins as a partnership of equals. Over time, the unreliable, messy, and otherwise unflattering behavioral characteristics of ADHD incessantly manifest themselves, leading to short-sighted resolutions. The partner with ADHD may repeatedly fail to pick up the cleaning, deposit money in the bank account, clean the house, mow the lawn, get the car repaired, or even pick up the children from school. As these mistakes persist, corrective actions are attempted. Last ditch efforts are considered and implemented to save the relationship. The nonADHD partner may scold the other for continuous failures, nag him/her to ensure the oversights are not repeated, or just take over the tasks herself to ensure they are actually done. These short-term patches exact a high price in the form of deepening resentments, shame, and dissatisfaction. They do not provide consequential solutions for the ADHD symptoms at hand. Instead, the resulting negative emotions undermine the stability of the relationship and cause damage to each partner (Orlov, 2013). As short-term reactions, they work only in the immediate timeframe. For sustained impact, they need to be continuously increased in intensity to the point that they become destructive. A partner with ADHD develops “tolerance” to constant nagging and shaming, requiring even bolder behaviors to facilitate any changes in their behaviors. This results in even deeper shame, anger, and bitterness. The damage of the attempted control behaviors thus outweighs any immediate benefits (Orlov, 2013). Resentment and disgust are common reactions for the non-ADHD partner, who feels that he is being forced into an oversight role in the relationship. Whether explicitly stated or not, thoughts of regret and questions about

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committing to this relationship may be present. If the partners are not yet married or cohabitating, these struggles may destroy the relationship. When the relationship does continue, it often evolves into one that more closely resembles a parent–child dynamic rather than one of adult equals (Orlov, 2013). For the partner with ADHD, the relationship issues may easily be interpreted as objective evidence of his/her worst fears: being defective, broken, and perpetually unreliable. This naturally leads to deeply internalized shame, degraded self-worth, and often depression. It is more evidence of personal inadequacy. While agreeing in part with the non-ADHD partner’s disappointment, resentment and anger develop toward the non-ADHD partner as part of this evolving parent–child dynamic. The partner with ADHD makes promises and commitments to change and sincerely intends to keep them. Yet without effective management of her ADHD symptoms, he/she falls short of these assurances. To the non-ADHD partner, it usually looks like a conscious choice to remain irresponsible, selfish, or immature. It is interpreted as a way to “get me to do the dirty work” that he/she doesn’t want to do (Koretsky, 2013). The partner with ADHD may even agree with these conclusions. In the longer term, the partner with ADHD often reaches a disturbing conclusion about her essential self: “I’m a bad person.” That is, she feels fundamentally flawed. This inference draws upon a painful (though biased) account of personal disappointments. It reflects a sense of shame about herself as being irreparably corrupted, rather than a more concentrated sense of guilt about some specific actions. Over time she may cope by withdrawing from the relationship, attempting to hide and cover up her failures, projecting shortcomings onto the other partner, acting out in anger, or numbing out with substances and/or other process addictions, such as video games, gambling, or overeating (Koretsky, 2013). These responses, of course, typically inflame the conflicts in the relationship even further. Some partners with ADHD develop anxiety about the other’s negative reactions and condemnations for wasting time, even as they feel paralyzed to do something about it (Koretsky, 2013). Countertransference Comments It is also important to recognize that as part of the therapist’s countertransference process, he may sometimes harbor feelings of judgment toward the partner with ADHD for her repeated struggles that align with the negative interpretations of the parent–child dynamic described above. The therapist may unconsciously assume that the client with ADHD is engaging in behaviors that are consciously manipulative, unmotivated, or indolent, rather than expressing natural signs of untreated adult ADHD. Another possible countertransference involves judgment and lack of empathy for the partner without ADHD. Here the therapist knowingly or unknowingly considers that partner’s reactions to the relationship to be

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inappropriate, callous, or selfish. An empathic appreciation that the partner without ADHD is manifesting natural (if erroneous) reactions toward a perpetually frustrating relationship experience is either decreased or absent. Regardless of the direction of the countertransference, it is vital that couple therapists be aware of the potential for these reactions to arise when working with couples impacted by ADHD. They may or may not be within the full awareness of the therapist. In working with couples impacted by ADHD, it is also important to consider personal biases and past experiences that might predispose one to a countertransference reaction. Consultation with a colleague or a more formal supervision relationship is often helpful in the understanding and appropriate management of a countertransference reaction. Communication Issues and ADHD The characteristic effects of ADHD on a relationship emerge largely within the couples’ communication patterns. The strength and quality of the relationship tend to degrade over time when ADHD is not well managed. Problematic communications in an ADHD-impacted couple include open conflict and hostility, passive-aggressive acting out, conflict avoidance, or variations of these communication styles. The partners’ motives for change are sincere, such that both want to address their relationship problems. Their steps for creating change are typically not effective, however, and may inadvertently harm the relationship. The interaction between ADHD-typical behaviors and strained communication skills yield patterns that are toxic to the relationship (Robbins, 2005). These include a tendency to provoke others and to pursue conflict; a hesitance backing down from one’s position in an argument; and a need to always have the last word in a conversation. Such communication habits are maladaptive for the long-term health of the relationship, although in the moment they may meet the short-term needs of a partner. Several symptoms of ADHD can derail a couple’s interpersonal interactions. Rapid emotional reactivity and unchecked behavioral impulsivity may contribute to an escalating conflict, or help facilitate problematic habits (e.g., spending sprees) that undermine the integrity of the relationship. In the big picture, Tuckman (2013) conceptualizes ADHD as the result of underdeveloped executive functions. These immature executive skills lead to impulsivity and dysregulation. These cognitive deficits threaten the healthy development and maintenance of a committed relationship. ADHD symptoms such as disorganization, procrastination, and hyperfocus destabilize many intimate relationships. Hyperfocus, a common unofficial trait of ADHD, is “unbroken attention. . . [in which] the person gets so absorbed in a current task that he loses track of time that is passing—time does not enter his awareness” (Tuckman, 2013, p. 66).

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A common error made by both partners in an ADHD-impacted relationship is to misinterpret the pathognomonic signs of ADHD as character flaws. ADHD symptoms such as impulsivity, procrastination, and inattention are misinterpreted as conscious personal choices that reflect laziness, dishonesty, and indifference. Distractibility and hyperfocus may be mistaken for apathy and selfishness (Maucieri, 2013). Frequent interruptions in conversation— likely reflecting the impulsive and impatient components of ADHD—are viewed as self-absorption and rudeness (Betchen, 2003). If recognized at all, ADHD is underemphasized in favor of personality flaws in these situations. Assessment Considerations Genogram The genogram is a common tool used for a variety of applications in couples and family therapy. Its construction allows a counselor to efficiently visualize and explore family dynamics, interpersonal alliances, and communication patterns. When working with a couple impacted by ADHD, a genogram may be informative as well. Using a genogram to chart relevant behaviors and relationships over several generations, a therapist can explore the hereditary and environmental aspects of ADHD with the impacted couple. Specific interpersonal patterns and acquired behaviors related to ADHD may emerge and be easily explored (Betchen, 2003). The genogram can be used an organizing tool to better understand patterns related to ADHD. Betchen (2003) suggested that clinicians inquire about the common symptoms of ADHD (e.g., lost items, procrastination, distractibility) as part of the collaborative genogram completion process. Diagnostic Assessment ADHD is over diagnosed and yet poorly understood. This dichotomy may stem from superficial training practices about the disorder and rushed diagnostic approaches. While some argue for brief symptom screenings to efficiently assess for ADHD, others advocate for a more detailed and meticulous diagnostic process. What is clear is that ADHD can rarely be definitively diagnosed in a brief interview. Self-report measures alone provide little conclusive diagnosis for or against ADHD; they are best used as initial screenings for the disorder (Tschudi, 2012). As ADHD symptoms are easy to feign and can closely resemble the symptoms of other disorders, clinicians must dig deeper before diagnosing a client with ADHD. Comprehensive psychological assessment is essential for older adolescents and adults concerned about having ADHD, but who manifested few or no signs of ADHD in childhood. The most reliable way to verify an ADHD diagnosis is with a psychological evaluation by an ADHD expert

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(Betchen, 2003). Numerous psychiatrists have also begun to rely on psychological evaluations for diagnostic confirmation, as many stimulant medications used to treat ADHD are Schedule II drugs in the U.S.A. While there is no signature profile for ADHD on standardized tests, the cognitive functions most often impacted involve working memory (multitasking), sustained attention, and executive functions, such as response inhibition and planning. Tuckman (2013) characterized ADHD as essentially a disorder of executive functioning. Aspects of processing speed and verbal memory may also be negatively affected. One complicating factor in the assessment process is that ADHD rarely travels alone. It is typically comorbid with depression, anxiety, dyslexia, conduct disorder, OCD, substance abuse, and/or tic disorders (Maucieri, 2013). Finally, certain neurologic conditions (e.g., traumatic brain injury) can look like ADHD in their symptoms. For these reasons, brief self-report screenings are helpful but not able to alone rule out ADHD and other comorbid conditions. Best Practices in ADHD Assessment Diagnosis of ADHD is best made from a careful review of the reported symptoms, collateral observations from knowledgeable others, and school documents when available. In practice, this level of detail is rarely obtained outside of a full psychoeducational or neuropsychological assessment for ADHD because of the time and effort required. The definitive diagnosis of ADHD involves exertion on the part of the clinician. Shortcut diagnoses may be correct occasionally, but they likely contribute to the over-diagnosis of ADHD. Several rating scales for ADHD throughout the lifespan have been developed with reasonable validity and reliability. Most of these can be completed quickly. These include the various Conners Adult ADHD Rating Scales (CAARS) and the Adult ADHD Self-Report Rating Scale (ASRS v1.1). The latter, developed by several ADHD experts in conjunction with the World Health Organization (WHO), is available online free. An updated version of the ASRS was released in 2018 to reflect the DSM-5 criteria for ADHD (J. R. Ramsay, personal communication, January 26, 2018). These scales provide an excellent initial assessment for possible ADHD, but they must be supported with cognitive tests, collateral information, and objective evidence for an accurate diagnosis. Comorbid conditions should also be ruled out. Diagnosing ADHD without ancillary evidence, collateral observations, or cognitive tests is risky. A growing literature demonstrates that normal control participants asked to feign symptoms of ADHD were easily able to do so on the CAARS and other self-report inventories (see Sollman, Ranseen, & Berry, 2010, for instance). Therefore, a comprehensive diagnostic approach for adult ADHD is essential.

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Cultural Considerations ADHD and Women The ADHD prototype for many of us is a hyperactive school boy or maybe a slacker male college student. For ADHD, we are more conditioned to visualize Jim Carrey than Lindsay Lohan. What we are very unlikely to think of, as an ADHD trope, is a quiet but disorganized woman. The ADHD prototype is usually an inattentive, sloppy, and impulsive male. This heuristic is not totally inaccurate, but it does ignore other manifestations of the condition. As a stereotype, it limits us from recognizing the heterogeneous presentations and populations in which ADHD occurs. ADHD remains largely overlooked in females. Roggli (2013) notes that this tendency probably results from a convergence of psychosocial and biological factors. Girls usually manifest their ADHD in more internalized and less behaviorally obvious ways than boys do. Traditional gender roles and socialization likely moderate their symptomatic expression of the disorder. Females with ADHD do experience procrastination, impulsivity, and distractibility, but how these symptoms appear may be different from males. When working with couples, we must acknowledge that we are socialized to recognize ADHD less in women than in men. Moreover, women with ADHD themselves often adhere to this bias, contributing to their enduring personal shame. They interpret their challenges as personal failures or character flaws, rather than symptoms of ADHD (Roggli, 2013). Identifying and challenging these entrenched preconceptions regarding ADHD within the treatment context can be enormously beneficial for couple involved. ADHD and Same-Sex Couples The legal and social changes for same-sex partnerships in the U.S.A. have been exponential in just the past decade. Still, some challenges and social stressors remain. Same-sex marriage is a legal right currently, but resistance persists among certain subgroups. New federal and state policies that deny LGBT individuals civil rights under the guise of religious freedom, for instance, clearly send a message of disapproval, whether it is intended or not. The marginalization and social stigmatization of LGBT individuals persist. These added pressures can strain LGBT couples impacted by ADHD in ways that are different from the usual effects of ADHD on relationships. Koretsky (2013) notes that internalized shame regarding LGBT identity, underdeveloped social support systems, and less defined roles within the relationship can all interact with ADHD to cause greater distress and tension for the couple. As therapists we must recognize and explore this confluence of stressors when working with LGBT couples impacted by ADHD.

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ADHD and Racially Diverse Couples The consequences of social or economic marginalization on racially diverse couples impacted by ADHD complicate the effects of the condition. Even in the clinical setting, marginalization may be propagated. Brooks and Waite (2013) recognize an established paucity of research on effective clinical techniques and assessment methods for African American individuals with ADHD. Clinicians are regrettably left with all-purpose models and unproven theories to try out on clients in need. Another complication in some diverse communities involves skepticism about ADHD as a legitimate condition. There may also be some reticence about trusting psychiatry and related fields, based on past instances of institutionalized racism in those disciplines (Brooks & Waite, 2013). For the couple impacted by ADHD, though, the net result is unmet treatment needs. Problems stemming from ADHD may easily be misattributed to laziness, indifference, or personal weaknesses. The couple then cannot work through and heal from the effects of ADHD. Therapist characteristics also must be considered. Mental health professionals often come from a position of privilege vis-à-vis gender, race, and/ or socioeconomic status. The therapeutic hour is not immune to these influences, and therapists must identify and remain vigilant of their own biases, assumptions, and values. The persistent effects of structural marginalization, cultural scripts, and internalized racism must be considered and addressed for a beneficial therapeutic outcome (Brooks & Waite, 2013). Recommendations for Work With Couples Couples approaches for ADHD are a new and evolving area of clinical focus. Several recent models are briefly described here. Social Skills Techniques Communication problems are widespread for many couples. Among those affected by ADHD, the symptoms of the disorder can augment these challenges by their inherent nature or due to misattributions related to awareness and motive. Clients with ADHD often have greater difficulty recognizing emotions, while struggling to inhibit their own emotional impulses (Bruner et al., 2015). Helping the couple to recognize these traits as natural elements of ADHD, while collaboratively developing skills with them to identify and manage the behaviors, is beneficial for their interpersonal communications and empowering for them as a cohesive unit. A non-judgmental exploration and reshaping of other ADHD behaviors may also improve the couple’s communications. For example, a therapist can help the partner with ADHD become more aware of his unintended non-verbal cues (e.g., yawning, looking at his watch) when communicating

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with his partner, while also helping the non-ADHD partner to not personalize these behaviors as rejecting or insensitive (Betchen, 2003). Similarly, the client with ADHD may learn internal cues to stop himself from speaking impulsively without preparation or before the other partner has finished (Betchen, 2003). Active listening skill development for both partners is usually beneficial for the relationship, and in certain situations, assertiveness skills training can vastly improve the couples’ communication patterns (Betchen, 2003; Paterson, 2000). Cognitive Behavioral Couples Groups Some clinicians have adopted techniques and interventions from individual CBT to help couples impacted by ADHD. Wymbs and Molina (2015) ran CBT groups of younger adult couples to strengthen communication effectiveness, self-regulation skills, and interpersonal problem-solving. This particular format allows for vicarious learning, role modeling, and a sense of universality that would likely be difficult to attain outside of a group context. Their treatment approach provided weekly development of self-regulation, communication, and relationship skills. They also included methods to defuse conflict, resolve problems, and understand common causes of arguments (Wymbs & Molina, 2015). Another important issue involves personal finances. Since money is often a point of contention for ADHD-impacted couples, a commitment from both partners to set goals and use specific financial strategies is helpful. Sometimes financial tasks are too overwhelming or stressful for the partner with ADHD. Depending on the ADHD symptoms involved and the complexity of the couples’ economic situation, it may be most efficient for the non-ADHD partner to assume responsibility for their budgets, finances, and bills (Sarkis, 2013). Like other CBT treatments, motivation in this model is implicitly assumed. When motivation is absent or degraded, the therapist must address it. CBT offers some potential techniques for these circumstances (e.g., behavioral chain analysis), but employing Motivational Interviewing as pretreatment to enhance therapeutic commitment (Arkowitz & Westra, 2009) may be more effective. Imago Relationship Therapy A different approach to working with couples impacted by ADHD is Imago Relationship Therapy (IRT). This model was included in a recently released book about couples therapies for ADHD (Pera & Robin, 2016). A significant goal of IRT is strengthening the couple’s listening and communication skills. Within IRT, the couple’s communication skills are improved using the couple’s dialogue (Robbins, 2005). This helps restore an

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empathic bond between the partners and provides tools for them to communicate their needs in a trusting manner. The couple’s dialogue relies on three components: mirroring; validating; and empathizing (Robbins, 2005). Mirroring is similar to the basic counseling skills that therapists learn early in their training. It may include reflections and summaries in the form of I-questions (Robbins, 2005). Validating involves affirmation of the speaker’s statements. It is not an absolute agreement with everything that was said, but an endorsement of the aspects of the message with which the listener agrees (Robbins, 2005). Empathizing involves the listener providing the speaker with supportive and considerate feedback to help affirm his/her messages (Robbins, 2005). Once all three components of the dialogue have been completed, the speaker and listener exchange roles and complete the couple’s dialogue again. Criticism and disapproval are discouraged. The couple’s dialogue occurs in a structured and reliable format, thus minimizing the risks of emotional reactivity, impulsivity, automatic responses, and conflict escalation (Robbins, 2005). The strengths of IRT for ADHD involve its strong focus on communication patterns and listening skills. IRT should probably be used in combination with other methods, however, to address the full range of problems in ADHD (e.g., forgetfulness, disorganization) that undermine the relationship and cohesion of the partners. For couples affected by ADHD, communication and interpersonal skills are necessary but not sufficient to treat all of their issues. Orlov’s Model Finally, Melissa Orlov (2013) developed a sophisticated model for working with marital partners impacted by ADHD. It cannot be described in detail here due to space limitations, but the interested reader is referred to Orlov (2013) for a deeper discussion of it. Her marital recovery model has three stages. In the broadest terms, it involves helping both partners to: (1) face and move on from denial; (2) make structural changes in the relationship; and (3) develop an enhanced sense of romance and connection (Orlov, 2013). Unlike the IRT and CBT models, Orlov’s approach was specifically tailored for couples distressed by ADHD. It is not a general psychotherapeutic theory that was subsequently applied to ADHD as well as other couples issues. In the initial stage her model, the couples’ communications tend to be strained and negative. The partner with ADHD is presumed to lack the effort to change his ADHD symptoms. At this point, the therapist can assist the couple with psychoeducation regarding ADHD symptoms and treatment options and provide support for the impact of ADHD on their relationship (Orlov, 2013).

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Orlov (2013) refers to the second stage as “the hard work” (p. 176), perhaps in a manner similar to Freud’s “working through” process as a core period of change in psychoanalysis. During this phase, both partners adapt their individual behaviors and strive to improve the couple’s interpersonal interactions. Communication skills development, boundary setting, and setting SMART goals are among the interventions employed. Common dysfunctional traps, such as the parent–child dynamic mentioned above, are identified and explored during this part of the therapy (Orlov, 2013). By the third stage of her approach, a sense of optimism and warmth has started to return. The work is not completely over, though. In this phase, the therapist helps the couple to build strong connections, develop an “intentional” relationship, and to consciously schedule time and make efforts as a couple to positively connect (Orlov, 2013). The strengths of this model are that it was developed specifically for couples with ADHD and that it is scrupulous in its stage-level problems, goals, and interventions. Its chief limitation is that it has not yet undergone empirical validation in clinical trials. Case Example: Mark and Karen Mark and Karen, two late 20s European-American Millennials, were a year into a volatile relationship when they moved into her condo together. Their relationship continued to flounder after that, as Karen became deeply dissatisfied with Mark’s unreliability, messiness, and deficient social skills. She resolved to break up on multiple occasions but always reneged, due to her unresolved childhood abandonment issues. Occasionally Mark would threaten to end it as well, but he quickly backed off as he suspected that he was the source of all of their problems and feared that he couldn’t function without her. After Mark lost his job due to major mistakes on several major accounts, a livid Karen insisted he see a therapist or she would throw him out. Fearful that she meant it this time, Mark saw a counselor, who suspected ADHD. In grade school, Mark was diagnosed with “the ADD,” as his mother explained it, after testing by his school psychologist, but neither his parents nor the school explained to him what that meant nor what to do about it. It was duly noted in a paper file and nothing changed. Now his counselor helped him recognize that his history of impatience, distractibility, hyperfocus, underachievement, and disorganization are all part of ADHD. As a boy he was restless and hyperactive, but that subsided by his late teens. Mark completed an updated psychological evaluation, and it suggested that ADHD was still a problem. His attention, multi-tasking, and executive functioning scores were all deficient, and his memory was also indirectly impacted. Moreover, personality results showed that Mark’s unaddressed ADHD led to deep self-loathing and degraded self-esteem.

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Although reticent at first, Mark eventually concurred with the counselor that medication for ADHD might be beneficial. He saw a recommended psychiatrist and was tried on Vyvanse. Mark and Karen both noticed that his focus and impatience improved. He still struggled with disorganization and time management, however. Mark’s counselor used cognitive–behavioral therapy (CBT) interventions to teach him strategies for managing his distraction, procrastination, and disorganization. He was taught to habitually use a paper planner. Later, his secondary anxiety was addressed with techniques involving visual imagery, thought stopping, cognitive restructuring of worry thoughts, and relaxation methods. Mark also began to exercise again and incorporated mindfulness into his morning routine, which were beneficial for his mood, stress level, and focus. While he made clear progress and eventually landed a new job, their relationship still struggled. After several candid talks, Mark and Karen began couple therapy to address the unresolved problems in their relationship. The therapist helped them both learn more about what ADHD was, and that Mark’s struggles were not due to laziness, selfishness, or other character flaws. Chores were examined and reallocated to take advantage of each partner’s natural strengths and interests, and they got done more often. Karen’s occasional perfectionism about neatness was identified and relaxed to a level that Mark could reasonably achieve in his tasks. The parent–child dynamic that had evolved was identified and both partners developed skills to avoid reenacting this old relationship pattern. Resentments held by both partners based on misunderstandings about ADHD were processed and resolved. Karen’s abandonment fears also emerged in the couples sessions and she opted to work with an individual therapist on them. Finally, the therapist helped Mark and Karen strengthen their communication skills. He learned to not cut her off midsentence when she provided him with visual and auditory cues, and she reconceptualized his behaviors as stemming from ADHD. They both benefitted from assertiveness skills training, development of clearer boundaries, and using I-statements in their regular conversations. After a year of couples sessions, they had sessions on an as-needed basis every few months and celebrated their recent engagement to be married. Conclusion It is only within the last few decades that clinicians and mental health experts have recognized that the symptoms of ADHD can sometimes persist into adulthood. Newer still is our appreciation of the impact of ADHD on intimate adult relationships. A  number of therapeutic models and clinical interventions, such as those described above, have been developed to fit the specific needs of couples that have been affected by ADHD in recent years. These approaches will ultimately empower couple counselors to uncover

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and address ADHD, as an often underappreciated stressor within intimate relationships. References American Psychiatric Association. (2013). Statistical and diagnostic manual of mental disorders (5th ed.). Washington, DC: Author. Arkowitz, H., & Westra, H. A. (2009). Introduction to the special series on motivational interviewing and psychotherapy. Journal of Clinical Psychology: In Session, 65, 1149–1155. Betchen, S. J. (2003). Suggestions for improving intimacy in couples in which one partner has attention-deficit/hyperactivity disorder. Journal of Sex and Marital Therapy, 29, 103–124. Brooks, S., & Waite, R. (2013). African American couples and ADHD: A multilevel approach. In L. Maucieri & J. Carlson (Eds.), The distracted couple: The impact of ADHD on adult relationships (pp. 101–122). Carmarthen, Wales: Crown House. Bruner, M. R., Kuryluk, A. D., & Whitton, S. W. (2015). Attention-deficit/hyperactivity disorder symptom levels and romantic relationship quality in college students. Journal of American College Health, 63, 98–108. Kessler, R. C., Adler, L., Barkley, R., Biederman, J., Conners, C. K., Demler, O., . . . Zaslavsky, A. M. (2006). The prevalence and correlates of adult ADHD in the United States: Results from the national comorbidity survey replication. American Journal of Psychiatry, 163, 716–723. Koretsky, J. (2013). Working with same sex couples in ADHD-impacted relationships. In L. Maucieri & J. Carlson (Eds.), The distracted couple: The impact of ADHD on adult relationships (pp. 143–171). Carmarthen, Wales: Crown House. Maucieri, L. (2013). ADD, ADHD, and adults: Sorting it all out. In L. Maucieri & J. Carlson (Eds.), The distracted couple: The impact of ADHD on adult relationships (pp. 3–32). Carmarthen, Wales: Crown House. Orlov, M. (2013). The ADHD effect marital recovery map. In L. Maucieri & J. Carlson (Eds.), The distracted couple: The impact of ADHD on adult relationships (pp. 175– 219). Carmarthen, Wales: Crown House. Paterson, R. J. (2000). The assertiveness workbook: How to express your ideas and stand up for yourself at work and in relationships. Oakland, CA: New Harbinger. Pera, G., & Robin, A. L. (2016). Adult ADHD-focused couples therapy: Clinical interventions. New York, NY: Routledge. Robbins, C. A. (2005). ADHD couple and family relationships: Enhancing communication and understanding through imago relationship therapy. Journal of Clinical Psychology, 61, 565–577. Roggli, L. (2013). It is different for women with ADHD in intimate relationships. In L. Maucieri & J. Carlson (Eds.), The distracted couple: The impact of ADHD on adult relationships (pp. 123–142). Carmarthen, Wales: Crown House. Sarkis, S. M. (2013). The cost of ADHD for couples. In L. Maucieri & J. Carlson (Eds.), The distracted couple: The impact of ADHD on adult relationships (pp. 311–332). Carmarthen, Wales: Crown House. Sollman, M. J., Ranseen, J. D., & Berry, D. T. R. (2010). Detection of feigned ADHD in college students. Psychological Assessment, 22, 325–335. Tschudi, S. (2012). Loving someone with attention deficit disorder. Oakland, CA: New Harbinger.

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Tuckman, A. (2013). Executive functioning weaknesses underlie ADHD symptoms. In L. Maucieri & J. Carlson (Eds.). The distracted couple: The impact of ADHD on adult relationships (pp. 55–82). Carmarthen, Wales: Crown House. Wymbs, B. T.,  & Molina, B. S. G. (2015). Integrative couples group treatment for emerging adults with ADHD symptoms. Cognitive and Behavioral Practice, 22, 161–171. Young, S., & Amarasinghe, J. M. (2010). Practitioner review: Non-pharmacological treatments for ADHD: A lifespan approach. Journal of Child Psychology and Psychiatry, 51, 116–133.

16 THE DOMESTIC VIOLENCE COUPLE Lisa Brown

T

he term domestic violence (DV) carries many connotations and elicits a wide array of reactions, as it conjures images of physical abuse, rape, and “battered women.” Domestic violence is associated with “battered women,” viewed by society as weak, irrational, uneducated, and helpless. It is often assumed to occur within a heterosexual relationship, and that only men are capable of battering and only women would tolerate abuse. Society routinely places blame on women in abusive relationships, as “she must have provoked the abuse.” DV issues are stigmatized and the partner often feels a great deal of shame because of the stigma placed on those in abusive relationships, especially if they stay with abusive partners. While domestic violence, or Intimate Partner Violence (IPV), can include physical abuse and sexual assault, this definition does not provide an accurate description of emotional abuse or the lasting effects of abusive relationships. Thus, the full scope and insidious nature of domestic violence is rarely acknowledged. To provide a thorough understanding of the nature of domestic violence, multiple forms of abuse will be defined. As abuse occurs in conjunction with multiple DSM 5 diagnoses, comorbid pathologies will be examined for both partners within the couple. A case example will be presented to demonstrate assessment, treatment, and cultural considerations of the domestic violence couple. Throughout the chapter, the terms “abuser,” “batterer,” and “perpetrator” will be used to describe the partner inflicting violence or emotional abuse. The term “survivor” will intentionally be utilized over “victim” to describe the partner being harmed or threatened as the goal of domestic violence advocates is to empower their clients by assisting them to find the strength to thrive and take back the power and control lost within the context of the abusive relationship. The term “victim” is a legal term applied throughout contact with police or the court system. While victimization is

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a consequence of domestic abuse, it also reinforces the negative stigma of helplessness, pity, and being trapped. This chapter explores counseling couples with a history of DV. Therefore, it needs to be acknowledged that couples counseling cannot be ethically conducted if there is abuse currently occurring within the relationship. The focus of this chapter is on working with DV couples with a history of abuse but not active/ongoing physical or sexual abuse. In work with abusive couples, counselors risk exacerbating the abuse suffered by survivors. Counselors are to establish an environment in which clients feel safe to disclose genuine emotions and share vulnerabilities. As survivors disclose their truth, the pattern of abuse utilized by abusers will be exposed, offering an opportunity for counselors to intervene. This resulting loss of power over the survivors drives batterers to punish survivors for revealing the true nature of the relationship. Due to the abuse suffered, survivors may discontinue counseling as the need for safety outweighs the help counselors may be able to extend. Should counseling continue, survivors may be less candid or even report that the presenting issues have been resolved. It is noteworthy that much of the literature on DV couples focuses on heterosexual couples in which the male partner is the abuser. Given the limited research on other DV couples (e.g., gay, woman-as-abuser, etc.), this chapter reflects this bias. However, information on the characteristics of abusers and survivors, as well as abusive relationship patterns, are still relevant to many diverse DV couples. Overview: Domestic Violence and Emotional Abuse As previously stated, DV is comprised of multiple forms of abuse—physical, sexual, emotional, and economic—manifesting in a systematic pattern of intentional intimidation for the purpose of gaining power and control over another individual (Domestic Abuse Intervention Project). A brief description of each type of abuse will be provided, and the cycle of violence will be discussed below. Physical Abuse Physical abuse extends beyond hitting, punching, or kicking and may include pushing, shoving, grabbing, slapping, choking, biting, spitting, burning, or stabbing and also includes other tactics to intimidate, coerce, and threaten. Intimidation tactics are a product of physical abuse previously suffered and exist on a continuum from subtle forms only recognized by survivors to overt expressions of terrorization. Abusers may use bodily gestures and looks to imply further physical abuse (Domestic Abuse Intervention Project). More blatant behaviors include destruction of survivors’ belongings, physical abuse of pets, and brandishing of weapons (Domestic Abuse Intervention Project). Coercion is a mechanism employed to exert power over survivors. Many survivors are forced by their abusers to commit illegal

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acts or to use substances (Domestic Abuse Intervention Project); engaging in these behaviors gives abusers leverage over survivors, allowing coercion to continue or escalate. Threats of harm are utilized when coercion tactics fail to gain the subordination sought. Should survivors attempt to discontinue the coerced behaviors, abusers threaten to make reports to the authorities. Other common tactics identified within the Power and Control Wheel (a model used to conceptualize types of domestic violence) include threatening to harm survivors or their children and threats to commit suicide (Domestic Abuse Intervention Project). Sexual Abuse Coercion in unwanted, unsafe, and degrading sexual activities is sexual abuse. Abusers exert control over every aspect of sex within a violent relationship by making demands in relation to the frequency, intensity, and type of sexual activities. Survivors are viewed as a tool for sexual gratification of abusers and may be forced to dress in a sexual manner, watch pornography, use alcohol or drugs during sex, or engage in sex with other people. Batterers will use derogatory sexual names, inflict injuries with weapons or objects, or purposefully pass on sexually transmitted infections to survivors during sex. Emotional manipulation during sex is common, as survivors are told they “owe” the abuser sex or sex is a way to “prove they love” the abuser. Sexual abuse is normalized with statements such as “If you won’t give it to me, I will get it somewhere else.” Recently, the term “reproductive coercion” has been introduced as a form of sexual abuse within heterosexual couples. Both men and women may be violated in this sense, as reproductive coercion refers to behaviors aimed at controlling the reproductive health of another individual. Sabotaging birth control methods are a form of reproductive abuse and include refusal to wear a condom, removal of a condom, poking holes in condoms, hiding birth control pills, or refusing to withdraw before ejaculation. Lying about sterilization surgeries (vasectomy/tubal ligation), forcing pregnancy, forcing abortion, or continually keeping a survivor pregnant are other forms of reproductive coercion. As with sexual abuse, emotional manipulation may play a role, as survivors may be pressured or shamed for not wanting more children. Emotional Abuse Emotional abuse is more difficult to define, as it includes multiple components: verbal abuse, isolation, minimization, denial, blaming, use of children, and use of male privilege (if abuser is male). Verbal abuse is comprised of insulting, berating, belittling, and name-calling with the intent to cause feelings of worthlessness and a lack of confidence.

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Isolation is a tactic in which abusers control survivors’ interactions with family and friends, whereby survivors are preventing from seeing and talking to others who may function as a source of support (Domestic Abuse Intervention Project). The behaviors of survivors may be closely monitored through the use of stalking or monitoring the use of phones, email, and social media accounts to limit the contact with the outside world. Abusers commonly use jealousy to justify these actions. Minimization, denial, and blame are often combined due to the result elicited in survivors and refer to the reduction of the abuse inflicted and discounting the injuries of survivors (Domestic Abuse Intervention Project). Frequently, the abuse suffered is denied and survivors are told, “that never happened” or “you must have dreamt it.” When batterers acknowledge abuse, the blame will be placed on the survivors, by explaining their hand was forced, as there was no compliance to his/her demands. Use of children is considered a form of abuse as children are often used to exert control over survivors (Domestic Abuse Intervention Project). Submission of the survivor may be gained through threats to take the children or to seek custody rights. In these situations, abusers’ motives may not to be to see the children more often, but rather an attempt to inflict emotional pain on the survivor. Abusers may exploit visitation to harass the survivor or to manipulate the children against the survivor, and it is not uncommon for batterers to use their children to deliver threatening messages to the survivor. Children often adopt the negative views of the survivor held by the abuser. Hearing emotional abuse from the abuser and the children exacerbates feelings of self-doubt and guilt of the survivor. Within the context of heterosexual relationships, use of male privilege is emotionally abusive as the abusers will make the major decisions within the home, define men’s and women’s roles rigidly, and treat the survivor as a servant (Domestic Abuse Intervention Project). In same-sex relationships, abusers can also utilize privilege through using their ability to “pass” as straight or cisgendered (when one’s assigned sex at birth matches one’s gender identity). This ability can be employed to discredit survivors or place them in dangerous situations. Economic Abuse The main goal of retaining economic control within an abusive relationship is to prevent survivors from financial resources that would enable them to leave their abusers. Forms of economic abuse include stealing survivors’ money, amassing debt on their credit cards, preventing survivors from retaining a job or obtaining a degree, controlling the survivors’ access to money or giving them an allowance, and keeping survivors’ names off joint assets (Domestic Abuse Intervention Project).

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Cycle of Violence The cycle of violence is a tool used to demonstrate the repetitive patterns of abusive behaviors utilized by batterers to prevent survivors from leaving the relationship. The cycle of violence is comprised of three stages: (1) tensionbuilding; (2) explosion; and (3) honeymoon stage (Walker, 1979). The duration and intensity of these stages vary among couples and within the same couple over time (Walker, 1979). The tension-building phase is comprised of escalation of abusers’ anger and physical intimidation towards the survivor. As this phase may last several weeks, escalation is gradual. Abusers exhibit a negative, often angry, mood to which survivors react with circumspection and attempts to placate abusers (sometimes referred to as “walking on eggshells”). Survivors suffer intimidation and minor physical assaults during this time, enabling abusers to maintain dominance. Tension-building comes to an end when abusers reach a breaking point, often triggered by an external event or abusers’ instability of mood and loss of control (Walker, 1979). Batterers’ loss of control is the hallmark of the explosion phase and is often the shortest phase of the cycle—two to twenty-four hours—but is the most violent (Walker, 1979). Survivors are at their most vulnerable during this phase as multiple forms of abuse are inflicted. Multiple methods of survival are employed during this stage, including attempts to leave, fighting back, dissociating, or “playing” dead. Calls to emergency services are typically made during this phase, as survivors may suffer lasting physical injuries and fear for their life (Walker, 1979). Emergency calls do not typically result in survivors receiving the medical care needed or filing of a report of the abuse. Once abusers are aware of the presence of first responders, they will take swift action to control their behavior, reigning in their temper. Threats of increased violence or violence against their children are made to maintain control over survivors, deterring reports of the abuse to first responders. Abusers will manipulate first responders by using their charm or placing blame on the survivor. This is effective as survivors have just been abused, fear the punishment promised, and may appear overly emotional or erratic in their behavior to authorities. When authorities ask survivors to describe the situation, abusers will use threatening looks or gestures to prevent survivors from reporting abuse, and survivors may deny the abuse or agree with the story supplied by abusers. The calm, charming demeanor portrayed by batterers and the “irrational” emotional expression or behaviors of survivors, invoking negative stereotypes of women, lead authorities to believe this narrative as well. In cases where authorities do not believe the narrative, they are unable to take further action to help survivors without a report of the abuse. Survivors’ feelings of despair grow as they suffer more severe injuries as punishment for

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attempting to seek help. Abusers’ feelings of power and control are affirmed as “not even the police can interfere.” The dissipation of violence and anger marks the end of this phase. The honeymoon phase follows the explosion and is characterized by disingenuous apologies from batterers. Feelings of remorse, promises to never abuse again, and declarations of love are communicated to survivors (Walker, 1979). Purchasing gifts, showering the survivor with attention, and other overly romantic gestures are made to lull survivors into a sense of relief and hope that the abuse will cease. Emotional abuse and manipulation continue to occur within this phase. To gain forgiveness from survivors, abusers may make threats to harm themselves or commit suicide, reporting the remorse felt is unbearable. Survivors adopt the blame abusers place on them and feel guilty for causing the abusers emotional distress. Once abusers gain the forgiveness of survivors, the cycle can begin again with the tension-building phase. DSM 5 and the Domestic Violence Couple While there is no corresponding DSM-5 diagnosis for domestic violence and emotional abuse, there are several diagnoses counselors should consider. Post-Traumatic Stress Disorder (PTSD) is a common diagnosis within the domestic violence couple. A review of PTSD is provided in Chapter 7 and will not be repeated here; however, it is critical for counselors working with DV couples to have an in-depth understanding of PTSD and its treatment, as it is common in DV couples. Especially relevant to DV couples are the intrusive PTSD symptoms (derealization, dissociation, flashbacks, the fight, flight or freeze response, hypervigilance, and an exaggerated startle response). Another core component of PTSD reported by survivors are negative alterations in cognitions. Survivors will report negative beliefs about themselves and assume blame for the batterer’s behaviors, effectively maintaining the emotional abuse and maintaining some loyalty and trust in the abuser. Research on survivors of domestic violence has also established a connection to Major Depressive Disorder, Persistent Depressive Disorder, and suicidality. Efforts to assess for a comorbid personality disorder are also warranted, as Borderline Personality Disorder co-occurs within the DV population. Finally, counselors should be aware of the prevalence of substancerelated and addictive disorders within the domestic violence population and emotionally abusive couple. To better meet the needs of couples, counselors need familiarity with the research on complex trauma, as the type encountered by survivors fundamentally determines the focus of treatment. Individual counseling should also be considered as an adjunct to couple therapy. The case study presented will provide an example of a couple in which both partners sustained abuse in former relationships. One member of the couple was also in individual

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counseling. Like many couples, the couple presented suffered from additional mental health diagnoses. Assessment Considerations When working with couples, a thorough assessment of each individual and the couple should be conducted. Each partner should be evaluated for a history of domestic violence or emotional abuse in childhood or previous intimate relationships. Family-of-origin issues pertaining to attachment, abandonment, and boundaries are crucial components of assessment, as these issues factor into each partner’s needs and level of satisfaction within the couple’s relationship. Patterns of abuse encountered in childhood or previous intimate relationships will likewise be carried over into the current relationship. An extensive assessment of abuse and the retelling of this trauma is not necessary and can be counterproductive, as while some individuals may find this process cathartic, others will find this traumatic. To gain a sense of the appropriateness of recounting the history of trauma, counselors should ask general questions to determine the intensity, frequency, and duration of the trauma sustained. As the client answers these questions, it is vital to look for any symptoms of dissociation Couples must be screened for any current abusive patterns, as the presence of physical abuse will prevent any progression within the framework of couples counseling. Evaluation of domestic abuse couples includes assessment of family-of-origin issues, communication patterns, trauma triggers, reenactments of the cycle of violence, expectations and views of gender roles, sexual intimacy, patterns of power and control, and boundaries. Case Conceptualization: Individual and Couple As each partner contributes to the functioning of the couple, an individual case conceptualization is presented to provide a thorough understanding of how the individual dynamics shape the couple’s relationship. With ethical treatment in mind, the couple case conceptualization below provides a framework for counseling a couple in which both partners have an abusive history, but no physical or sexual abuse is occurring. Individual Case Conceptualization A strong case conceptualization informs the treatment process as it allows for the formation of realistic treatment goals, respects and reflects clients’ culture, and meets the clients’ identified needs. Specific to clients with a history of domestic violence, it is imperative to understand the trauma experienced and the current impact of the trauma. Clients with a history of domestic violence often present as restless, suspicious, secretive, dependent, and submissive (Walker, 2017). Rather than pathologize, counselors working

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with domestic violence survivors will recognize these behaviors as necessary components of survival. As survivors have been brutally hurt by those closest to them, they do not trust easily, making it difficult to build the healthy relationships. Couple Case Conceptualization The goal of the couple’s case conceptualization is to organize and integrate each partner’s individual dynamics into the context of the relationship. Given the presence of domestic violence history and emotional abuse, the case conceptualization should include parental relationship dynamics, attachment patterns, attitudes and beliefs regarding physical and sexual intimacy, and interactions of trust. Based on their previous abusive relationship dynamics, survivors may exhibit a rigid belief system based on the unhealthy views of abusers (Walker, 2017). Some of the beliefs held by survivors are closely tied to cultural values and have been exploited for the purpose of maintaining power and control. This exploitation is especially visible when considering gender roles and expectations. Female survivors may place great emphasis on their role as homemakers, mothers, and wives. As such, they are to nurture, meet the needs of their spouse, and defer important decision to him to maintain relationship happiness and satisfaction. When partners’ needs are not met, the survivors are to blame and have failed in their role as women. Survivors hold maladaptive views of themselves stemming from the emotional abuse sustained and do not expect their boundaries to be respected (Walker, 2017). Survivors never completely trust others, as batterers have chronically broken their trust. Respect is not anticipated and may be questioned due to the manipulation sustained from abusers. Survivors carry tremendous inappropriate guilt that clouds their thinking and often do not feel they deserve to heal from the trauma sustained. Cultural Considerations Culture is a multifaceted construct comprised of race, ethnicity, sex, gender, religion, age, sexual orientation, and social class. Each of these constructs influences views of roles and expectations within a relationship. The variation of cultural identities and level of acculturation of each partner will impact not only the functioning of the couple but also the relationship the couple shares with the counselor. As domestic violence and emotional abuse occur within the context of intimate relationships, a predominating cultural factor is gender, especially for DV heterosexual couples where strict gender roles often exist. Restrictive expression of vulnerable emotions is often valued, and overt expressions of anger and jealousy are tolerated. Each of these aspects can be overemphasized,

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leading easily to domestic abuse. Along with stricter gender roles comes the assumption that women are viewed as a reflection of their husbands, leading men to believe they need to monitor their wives’ contact with others. Just as ethnicity impacts beliefs about gender, religion can also influence this view. Men and women may believe rape does not exist within the context of marriage, as men are sexual beings and women are responsible for bearing children; thus, the use of birth control may be restricted, allowing abuse of reproductive rights. Same Sex Couples Rates of domestic violence and emotional abuse within same sex couples are equivalent to those seen within heterosexual couples; however, it is often minimized and ignored (Peterman  & Dixon, 2003). One prevalent myth states violence does not occur in male same-sex relationships as men are naturally aggressive and solve problems physically. Men are assumed to physically defend themselves; therefore, one cannot overpower the other. For female same-sex relationships, the assumption of women lacking violent or abusive tendencies maintains silence around domestic abuse. Common to all LGBT intimate relationships is the threat of reporting domestic abuse, requiring the couple to expose the nature of their relationship to law enforcement and society. Treatment Considerations The history of domestic violence and emotional abuse informs the treatment modality, counseling process, and treatment goals. For those with abusive relationship histories, individual treatment is indicated. It is not necessary, nor appropriate, for all survivors to actively work to resolve their trauma (Rothschild, 2010). However, counseling for all survivors of domestic violence includes psychoeducation on the mechanisms of domestic violence, analysis of the maladaptive relationship dynamics, development of coping skills to address flashbacks, and assertiveness skill training. Without individual counseling allowing survivors to work on these goals, couples counseling is unlikely to provide lasting effects. Effective couples counseling of the domestic violence couple is comprised of three stages: (1) establishing safety; (2) developing understanding of domestic violence; and (3) fostering healthy relationship patterns. 1.  Establishing Safety Treatment of domestic violence and emotionally abused couples begins with establishing safety in conjunction with education on the mechanisms of domestic violence (Walker, 2017). As survivors have not been afforded safety in previous relationships, they will rely on maladaptive cognitive, affective,

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and behavioral patterns of the past to ensure continued survival in the current relationship. By establishing a consistent environment of safety, survivors can allow themselves to be vulnerable and take a healthier approach to the current relationship. Throughout counseling, counselors should monitor the process and content of counseling to prevent continuation of the couples’ emotionally abusive patterns. Raising the couple’s awareness of these patterns is a key part of treatment. Counselors also need to acknowledge the various aspects of safety needed by clients as survivors need to feel secure to communicate their thoughts and emotions openly without fear of punishment or manipulation. Survivors also need validation of and assistance to combat the automatic responses of fight, flight, or freeze throughout the process of counseling. Partners of survivors need assurance of safety as they fear being blamed for the strain within the relationship or re-traumatizing the survivor (MacIntosh & Johnson, 2008). Through psychoeducation, survivors can label and identify their trauma, indicating type, duration, frequency, and intensity, but retelling the story of abuse may not be necessary. It is the act of witnessing the previous abuse within the context of couples counseling that leads to recovery, as it validates the trauma undermined by abusers use of minimization, blame, and manipulation (Nasim  & Nadan, 2013). Witnessing can be two-fold in couples counseling; counselors observe the recreation of the trauma within couples’ relationships and partners of survivors witness the lasting effects of trauma within survivors (Nasim  & Nadan, 2013). An explanation of PTSD and complex trauma symptoms further acknowledges the depth of the trauma effects, validating survivors and incorporating partners into treatment. With a shared knowledge of domestic violence, both partners can work to identify ways in which trauma responses and mechanisms of domestic violence are contributing to the presenting issues. 2.  Developing Understanding of Lasting Effects of Domestic Violence A common issue for couples with a domestic violence history is the triggering of trauma responses within the survivor. Survivors unknowingly recreate the cycle of violence and power dynamics in their relationships, casting partners in the role of “abuser.” Partners are often confused by these dynamics and unintentionally escalate conflict, further re-traumatizing survivors. As clients may be reluctant to admit to experiencing or perpetrating domestic violence, psychoeducation is again a helpful approach. Concrete examples or diagrams of the Power and Control Wheel and the cycle of violence can help clients to expand their understanding. With this knowledge, they can work together to identify how they contribute to their unique abusive relationship patterns. Themes that should be considered include expressions of anger, emotional regulation, communication patterns, demonstrations of

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empathy, potential dependency, negotiation and expression of sexual activities, boundaries, and assertiveness (Fruzzetti & Levensky, 2000). Processing of emotions should be of clinical focus during this stage. Clients may accuse each other of inflicting abuse, escalating the couple’s presenting issues. Encouraging clients to identify and disclose underlying soft emotions such as vulnerability, shame, and guilt can reframe the presenting problem in terms of the emotional needs of the individuals (Beckerman & Sarracco, 2002; MacIntosh & Johnson, 2008). 3.  Fostering Healthy Relationship Patterns Identification of underlying vulnerable emotions helps to shape positive couple interactions (Beckerman  & Sarracco, 2002) as it assists couples in creating new patterns of communication through displays of empathy and greater acceptance of each other’s emotional needs. A common challenge for those with an abusive history is showing vulnerability, and it is common for clients to struggle and regress at this stage. Normalizing and processing the survivor’s frustration can be helpful during this phase of treatment. Counselors can also encourage demonstrations of validation from the couple, which can help maintain the feeling of safety (Fruzzetti & Levensky, 2000). Other interventions can include the teaching of intra and interpersonal coping skills, emotional regulation strategies, and direct-action problemsolving coping skills (mindfulness), which can reduce the likelihood of re-traumatization and increase coping in times of distress (Walker, 2017). Finally, counselors can foster clear, genuine, and assertive communication, establish the couple’s resiliency, and help them establish appropriate interpersonal boundaries within the relationship. Case Example: Ricky and Mateo Ricky and Mateo had been partners for eight years when couples counseling began. Ricky was a 32-year-old second-generation Mexican American survivor of domestic abuse. He identifies as gay and came out to his family at the age of 21. Ricky reported his mother struggled to accept his identity initially but has become more accepting over time. Ricky’s step-father was less accepting and asked Ricky not to “flaunt his sexuality” when they are together. Ricky reported feeling hypervigilant and careful of how he interacts with his partner when in his step-father’s presence. He recently began individual counseling to cope with trauma sustained in a previous relationship. Ricky was diagnosed with PTSD and is working on managing intrusive symptoms and negative alterations in mood and reintegrating his memories of abuse in the hopes of recovering from previous domestic violence. Ricky had been in individual counseling for six months prior to beginning couple therapy with his 36-year-old partner, Mateo. Over the course of individual

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treatment, Ricky has become aware of the recreation of the cycle of violence and how his current partner was inadvertently triggering his abuse history, causing him to be emotionally reactive in psychologically destructive ways. Ricky and Mateo were referred for couples counseling. Mateo emigrated from Colombia with his parents at the age of 16 and reported he struggled to complete high school in the United States as he did not speak fluent English. Mateo was discouraged from applying to colleges after graduation and began working in the trades with his father. Mateo has not come out to his family as he knows they will not be accepting and would react with violence. They believe that Ricky is his roommate. This causes a strain on the couple’s relationship. The potentially violent reaction of Mateo’s family was attributed as the main reason the couple was not married. Assessment Considerations and Individual Conceptualizations Each partner completed an individual biopsychosocial interview as part of the assessment process. Both partners were assessed for domestic violence in their family of origin and romantic relationships. The couple then attended a joint session in which a couple’s assessment was completed. Ricky In his family of origin, Ricky sustained physical and emotional abuse at the hand of his alcoholic father until he was 9 years old. Although Ricky’s mother and two older brothers were also abused, Ricky reported he sustained more frequent and intense abuse than his family. He attributed this difference to his sexuality and stated, “he knew who I was before I did.” His father would use derogatory language and homophobic slurs when referring to Ricky; physical beatings were meant to teach masculinity and traditional male roles. As a child, he stayed with various family members to recover from injuries inflicted by his father. When Ricky was 8 years old, he was hospitalized with a broken collarbone; this incident lead Ricky’s mother to seek a divorce. Ricky believes that his mistrust of others stems from his anger towards his father for the abuse and towards his mother for failing to protect him. As a teen and young adult, he reported engaging in risky sexual relationships and had at least two abusive partners who ascribed to a hypermasculine identity. Mateo Mateo was the youngest of five boys in his family of origin in which his parents rarely showed warmth and affection. Government unrest and violence in Colombia escalated throughout the 1990s. Mateo’s older brother was recruited into a guerilla group and was killed in the conflict, leading the family to seek immigration into the United States. Assessment of Mateo’s family of origin revealed patterns of emotional and physical abuse. Mateo reported he experienced more emotional abuse as his

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mother often protected him from physical abuse. As such, Mateo’s father believes he is weak as he was “babied” by his mother. Mateo attempted to meet his father’s expectations by adopting stereotypical male behaviors in attempts to counteract his family’s homophobic attitudes. Mateo made several self-deprecating comments throughout the assessment and reported he felt he failed his family and Ricky. Mateo reported coping with feelings of depression through social withdrawal and drinking alcohol. He denied the presence of any form of domestic abuse occurring while intoxicated. DSM-5 After gathering all relevant data, Ricky and Mateo were both determined to have PTSD. Mateo also met the DSM-5 criteria for Persistent Depressive Disorder. Couple Case Conceptualization As a couple, Ricky and Mateo’s complex trauma history, including experiences of DV within their respective families of origin, significantly impacts their relationship. When triggered, Ricky’s survival skills were used to control Mateo to regain a sense of power within their relationship. This resulted in verbal attacks on Mateo. Their interaction is characteristic of the cycle of violence. The pressure Mateo felt to appease his family’s gender expectations led him to adopt hypermasculine behaviors. After years of attempting to please major attachment figures with little approval, Mateo felt chronic disappointment. He internalized the criticism of his parents and Ricky, leading to inappropriate guilt and low self-worth. Mateo’s hypermasculine behaviors served as the most prominent trigger of the abuse Ricky survived. While Mateo was not violent when he drank, the smell of alcohol caused Ricky to experience flashbacks. Ricky responded by criticizing Mateo’s drinking behaviors. Ricky accused Mateo of a lack of concern for his history of trauma and failing to prioritize their relationship. These accusations caused Mateo to question whether he was abusing alcohol despite rarely drinking to the point of intoxication. Mateo’s feelings of guilt were compounded by Ricky’s assertion that he did not feel Mateo was invested in their relationship. Mateo felt he was unable to meet Ricky’s needs and felt that Ricky would eventually leave him for someone better. Mateo would drink to cope with feelings of inadequacy and hopelessness, struggling to identify his own emotional needs. The status of Mateo and Ricky’s relationship contributed significant issues that were not initially understood by either client. For example, both men were at different levels of comfort in their respective gay identities and differing levels of acculturation in being Latino. Ricky understands how

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homosexuality is viewed in Latino culture and repeatedly informed Mateo that he did not want to be married, though he values their commitment to one another. Avoiding marriage was another way in which Ricky attempted to maintain control of the relationship. Thus, should Mateo become physically abusive, it would be easier to end the relationship. Mateo finds himself struggling to demonstrate his commitment to Ricky without proposing marriage. Cultural Considerations Ricky, a second-generation Mexican American, was moderately acculturated. While valuing traditional Mexican values, he strongly identified as a gay man. He was insightful to the internalized homophobia he carried and was motivated to foster a stronger sense of pride. Ricky’s understanding of his own culture’s views of homosexuality allowed him to empathize with Mateo’s fear of coming out to his family. Ricky was out to family, co-workers, and friends. At times, Ricky struggled in interactions with Mateo’s family as he felt as though he was “back in the closet.” Mateo identified as Colombian and struggled to develop his identity as a gay man, and often does not feel a sense of belonging within gay culture. Mateo views gay male culture negatively and has little interest in becoming more involved with the gay community. Mateo is not out with family or at work and is exhausted from hiding the true nature of his relationship with Ricky. Mateo lacks a support system as he cannot come out to his family and is not interested in support from the gay community. Treatment Considerations The primary concern for treatment is the establishment of safety within the relationship. As the couple was engaging in emotional abuse, counseling began with coaching healthy communication patterns to foster a sense of safety. The couple was encouraged to communicate without hostility or criticism and to verbalize concern and kindness. Ricky was actively working with an individual counselor to cope with symptoms of PTSD through grounding techniques. As such, Ricky was encouraged to share aspects of the abuse he sustained previously and to identity the triggers causing his flashbacks. Mateo’s validation of Ricky’s trauma demonstrated empathy and a regard for Ricky’s emotions. In turn, Mateo divulged the impact Ricky’s criticism had on his self-worth. Ricky was able to gain insight into how his anger and criticism deeply hurt Mateo. This deeper sense of understanding and empathetic responses allowed the couple to begin repairing their relationship. Both clients were encouraged to use grounding and relaxation techniques to maintain safety and regulate emotions throughout the course of treatment. Insight into how abusive histories influence the current relationship is necessary to foster more permanent changes. Using the Power and Control

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Wheel, each partner was challenged to identify ways in which he attempted to exert power and felt controlled by his partner. These tendencies were explored through an emotional and cognitive lens. Mateo was able to see how drinking numbed his feelings and his fear of communicating his needs. He was able to connect how his lack of asserting his needs worsened his selfworth and feelings of depression. Ricky took responsibility and apologized for demeaning Mateo. Ricky’s honesty and accountability for the emotional abuse he inflicted validated Mateo and increased his own understanding of the effects of domestic violence. Mateo verbalized wishes to demonstrate his commitment to their relationship and confronted Ricky on attempts to prevent Mateo from doing so. Mateo appropriately confronted Ricky’s tendency to disregard his contributions to their relationship and his unwillingness to allow Mateo to share in decision-making and household responsibilities. Ricky was disturbed by his exertion of power and developed insight into how he recreated the cycle of violence in his current relationship. Ricky expressed great discomfort in communicating feelings of vulnerability to Mateo due to a fear of exploitation of these feelings. Issues of safety resurfaced and treatment regressed to address Ricky’s need for safety. As needed, relaxation and techniques were used to deescalate and Ricky’s responses were normalized. Mateo was encouraged to communicate understanding and validation of Ricky’s fears given his previously abusive relationship. From a cognitive perspective, both men used thought-stopping and positive self-talk techniques. These techniques were modeled and practiced when maladaptive thoughts arose. Negative automatic thoughts learned from their respective abusers were challenged and restructured within each session. Ricky worked to control exaggerated negative beliefs and expectations (i.e., “Mateo cannot be trusted”) through cognitive reframing. Mateo developed assertive communication skills to advocate for his needs within the relationship. To further develop healthy relationship patterns, power within the relationship was redistributed. Mateo shared a need to overcome feelings of emasculation by contributing in significant ways to their relationship. Through negotiation, Ricky and Mateo agreed upon specific responsibilities for Mateo. Both partners were encouraged to remain honest and accountable for their actions as they navigated these responsibilities. Clinical Outcome Ricky and Mateo were motivated to create a healthy relationship based on equality and emotional validation. During the course of couples counseling, Mateo began individual counseling to address his trauma history and Persistent Depressive Disorder. Mateo reported increased self-worth and an ability to better manage his symptoms. Ricky continued with individual counseling

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to continue to manage his need for power and control within their relationship. Ricky struggled to deepen the trust extended to Mateo but remained willing to compromise and share some responsibility. After one year, Ricky and Mateo discontinued couples counseling. However, both remained in individual treatment to build upon the progress made in couples counseling. Conclusion To effectively treat domestic violence and emotional abuse couples, counselors must understand the intricacies of the various forms of abuse and how these interact with the dynamics of power and control to reinforce the cycle of violence. Treatment includes multiple and interconnected goals, requiring counselors to shift focus between the past and present. Couples treatment in conjunction with individual treatment is imperative to eliminating dependency, regulating emotions, establishing assertiveness, and developing a sense of self-worth and identity. By establishing emotional safety within the therapeutic relationship, couples can establish healthy boundaries, trust, and emotional validation within their relationship. Providing couples with the insight and tools to manage trauma symptoms and increase effective communication allows the couple to establish habits to maintain a healthy, longlasting relationship. References Beckerman, N. L., & Sarracco, M. (2002). Emotionally focused couple therapy: Intervening with an emotionally abusive couple. Journal of Couple & Relational Therapy, 1(3), 57–70. Domestic Abuse Intervention Project. Power and control wheel. Duluth, MN. Retrieved from www.theduluthmodel.org/wp-content/uploads/2017/03/Power andControl.pdf Fruzzetti, A. E., & Levensky, E. R. (2000). Dialectical behavior therapy for domestic violence: Rationale and procedures. Cognitive and Behavioral Practice, 7, 435–447. MacIntosh, H. B., & Johnson, S. (2008). Emotionally focused therapy for couples and childhood sexual abuse survivors. Journal of Marital and Family Therapy, 34(3), 298–315. Nasim, R., & Nadan, Y. (2013). Couples therapy with Childhood Sexual Abuse survivors (CSA) and their partners: Establishing a context for witnessing. Family Process, 52(3), 368–377. Peterman, L. M., & Dixon, C. G. (2003). Domestic violence between same-sex partners: Implications for counseling. Journal of Counseling & Development, 81, 40–47. Rothschild, B. (2010). 8 Keys to safe trauma recovery: Take-charge strategies to empower your healing. New York, NY: W. W. Norton & Company. Walker, L. E. (1979). The battered woman. New York, NY: William Morrow. Walker, L. E. (2017). The battered woman syndrome (4th ed.). New York, NY: Springer.

PART III

Developmental Issues Impacting Couples

17 THE SANDWICH GENERATION Stage of Life Issues in Couples Ken Oliver

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hile previous chapters in this text focus primarily on intrapsychic forces that undoubtedly add to the complexities of successful relational coupling, this chapter shifts the focus more to external forces that potentially cause or exacerbate psychological dysfunction in one or both members of a couple. A great deal of developmental psychology literature suggests a bevy of developmental tasks and milestones undertaken by individuals and, by relation, couples throughout the lifespan (Newman & Newman, 2014). These developmental classifications are not meant to be prescriptive but rather represent normative processes that have been become routine in Western culture. As is true with all forms of lifespan development, the reciprocal interplay between the individual self and responses to the environment helps to promote situational outcomes. These outcomes, in the aggregate, become part of how we define ourselves (i.e., identity) and the world around us (i.e., worldviews or schemas). These once-personal definitions and worldviews, now part of coupling, compound to help form our collective identities as couples. Overview on Research of Couples’ Stage of Life Issues While individuals and couples often plan to reach societally accepted developmental milestones, environmental factors sometimes throw even the most planful couple for a loop. These “curveballs” may include life-altering changes such as spousal death and resulting bereavement, the need or desire to take on additional caregiving roles for relatives (e.g., children, grandchildren, elderly parents, or other extended family members), or other life-changing occurrences that cause couples to set aside well-conceived plans. At those times, couples may find themselves questioning their collective identity.

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They may feel directionless and are apt to displace their frustration with the life change onto one another. They may erroneously look to their partners to fix the situation or protect them from additional frustration. The once flourishing and cohesive couple may now resemble a fragmented, desolate shell of the past relationship. Many couples, like their individual counterparts, are simply ill-prepared to deal with the infusion of these life stressors alone. Therefore, these stage of life stressors are often a primary cause for these disordered couples to seek treatment. Sandwich Couples The term “sandwich” has been applied to caregiving roles since the early 1980s to describe caregivers of individuals who are at least one generation lower (e.g., children or grandchildren) while simultaneously serving as caregiver to individuals of at least one generation higher (e.g., parents or grandparents) (Dobson, Russell, & Dobson, 1985). A wealth of research exists on the effects of sandwich caregiving on the individual; however, little to no research has been conducted to date on the effects of sandwich caregiving on the couple. This chapter intends to bridge the gap between research, findings, and treatment recommendations for individual sandwich caregivers and the lack of understanding regarding the effects of sandwich caregiving on the collective coupling. Individual sandwich caregiver research outlines several potentially damaging effects resulting from engaging in this type of caregiver role. Negative effects include, but are not limited to, depression (Boyczuk & Fletcher, 2016), financial distress (Doley, Bell, Watt, & Simpson, 2015), grief (Backhouse & Graham, 2013), increased compression between home and workplace responsibilities (Buffardi, Smith, O’Brien,  & Erdwins, 1999), and relational and communicative strain (Hammil, 1994). Additionally, caregivers of elderly parents often report an overwhelming sense of burden (Montgomery, Stull,  & Borgatta, 1985), and caregivers of grandchildren often report a sense of role confusion and perceived inadequate social support (Doley et al., 2015). We can assume that caregiving roles for parents who suffer from neurocognitive disorders pose even more risk of negative caregiver outcomes (Solberg, Solberg,  & Peterson, 2014). These negative outcomes present for the individual are also likely to impact the individual’s role in the couple and, in turn, the couple itself. While psychological dysfunction can be a likely outcome of sandwich caregiving, everyday functional complications also arise anytime a couple takes on new caregiver roles. Modifications to daily calendars, routines and schedules, monetary challenges, lack of interpersonal fit, changes to group (i.e., family) dynamics, and perceived lack of time/energy to focus on the couple, along with a host of other day-to-day challenges, add to the distress assumed when becoming a sandwich couple.

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The American Psychological Association (APA) published the Resolution on Family Caregivers (2011), which outlined relevant statistics on the rise of non-traditional caregiving for children and elderly parents along with corresponding professional edicts calling for support of clinicians and families alike with information and continued advocacy. This call for action signified a key step in effectively preventing this phenomenon from becoming an epidemic. Spousal Bereavement A wealth of mental health literature exists surrounding the issues of grief and loss. Like sandwich caregivers, spousal caregivers are likely candidates for increased distress and other ailments, believed to be directly related to the caregiving role itself (National Alliance on Caregiving, 2005). When spouses and spousal caregivers lose their partners to illness or unexpected death, spousal bereavement becomes the relevant psychosocial and psychological hurdle. Spousal bereavement, like other forms of bereavement, has the potential to lead to significant psychological distress and may manifest itself as mood, anxiety, or other DSM-5 disorders (Ott, Lueger, Kelber,  & Prigerson, 2007), particularly when left unexamined. DSM-5 Considerations Relationship Distress With Spouse or Intimate Partner This diagnostic code is recommended when a couple presents with significant relational distress that leads to problems with functioning (i.e., occupational, interpersonal, or other). Symptoms of this “other condition that may be the focus of clinical attention” may include issues related to cognitive, behavioral, and/or affective domains. Cognitively, individuals may develop dysfunctional thoughts and beliefs about the self and/or one’s intimate partner that serve to heighten the couple’s discord. Behaviorally, individuals may develop anticipatory and responsive behaviors that effectively stifle the couple’s collective growth. Affectively, individuals may become so consumed with their own emotion, or apathetic to their partner’s, that they fail to connect with their partner in an emotionally reciprocal manner. Regardless of the type of couple distress, these couples often find themselves at a functional impasse (American Psychiatric Association, 2013). Adjustment Disorders Adjustment Disorders represent a class of disorders related to an individual’s response to stressors that warrants clinical attention due to the disruption. Symptoms must result within three months after the existence of the

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stressor. The response has to be deemed to be excessive in regards to the initial activating event or situation (i.e., includes bereavement) and, like all DSM-5 diagnoses, the response has to cause significant impairment in the individual’s functioning. Also, to satisfy criteria for an Adjustment Disorder, the excessive response cannot continue for more than six months after the stressor has subsided nor can the response meet criteria for another mental disorder. Adjustment Disorders can present with depressed mood, anxiety, mixed depression and anxiety, conduct disturbance, mixed conduct disturbance and emotions, or unspecified. While transitional in nature, the presence of Adjustment Disorders can cause a wealth of functional complications and may be indicative of more severe, long-lasting conditions (American Psychiatric Association, 2013). Other Related Disorders The DSM-5 depicts several additional disorders that may be of clinical value when working with “sandwich couples” and couples dealing with other stage of life issues. In general, it would behoove clinicians working with couples dealing with psychosocial stage of life issues to be well-versed in diagnostic criteria that may be relevant to their particular client issues, such as Dementia, cognitive decline/impairment and other neurocognitive disorders often seen in declining parents, and Attention-Deficit/Hyperactivity Disorder, Oppositional Defiant, Conduct Disorder, and other behavioral and learning disorders often seen in children and adolescents. Specific to bereavement, couples and family clinicians would benefit from having a working knowledge of both Uncomplicated Bereavement and Persistent Complex Bereavement Disorder as almost all couples face bereavement and loss over the lifespan. Familiarity with these specific disorders, along with general mood and anxiety disorders, will serve as an invaluable asset to clinicians working with couples dealing with complex stage of life issues (American Psychiatric Association, 2013). Couple Case Conceptualization Case conceptualization for couples serving as “sandwiched” caregivers, or couples dealing with other stage of life issues such as spousal death, should include an increased focus on psychosocial elements while remaining cognizant of the cultural conditions that make them relevant. Similar to other areas of focus in couple therapy, it is recommended that an understanding of the cognitive, behavioral, and affective domains be explored (American Psychological Association, 2011). This understanding, from a conceptual standpoint, will undoubtedly be directly tied to the clinician’s underlying theoretical worldview; therefore, the clinician’s theoretical orientation should always be understood as a precursor for appropriate case conceptualization.

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Overall, clinicians would do well to conceptualize couples dealing with stage of life issues, like all couples, in as comprehensive a manner as possible. A comprehensive case conceptualization will, from a theoretical lens, examine the onset of precipitating issues, explore social supports or lack thereof, evaluate contributing stressors, explore various components of the couples’ expressed attitudinal structures (i.e., cognitive, behavioral, and affective), and identify a reasonable prognosis based on anticipated treatment effectiveness and compliance. With sandwiched couples, the precipitating issues will likely reflect initial changes in the caregiver role. In terms of social supports, couples who feel more support for their caregiving functions tend to report higher levels of satisfaction with their caregiver roles (Krause & Markides, 1990). Contributing stressors may include career-related commitments, caring for a disabled child or parent, perceived lack of partner support, and increased financial distress along with numerous other factors that add to the couple’s perceived burden. The evaluation of attitudinal structures provides, at minimum, two critical purposes as part of the case conceptualization process. First, the exploration of cognition, affect, and behavior helps to provide robust information and perspectives, particularly as it relates to how members of couples see themselves and their partners. In fact, it can be argued that the discrepancy in each member’s analysis of the couple’s attitudinal structures could, in itself, provide enough therapeutic fodder to last a lifetime. Second, the amount of focus on each attitudinal domain (i.e., cognitive, affective, and behavioral) will likely depend on the clinician’s preferred therapeutic orientation. Developing a reasonable prognosis involves more than simply stating whether the outcomes are likely to be successful. Clinical prognosis takes all of the relevant conceptual factors and offers a wellinformed hypothesis based on a wealth of clinical data. Ideally, the prognosis should not only make a prediction about the likely outcome but provide a treatment roadmap to identify areas of concern that may prove critical to the attainment of treatment success. Assessment Recommendations In work with couples dealing with stage of life issues like sandwiched caregiving and spousal death and bereavement, the clinical interview serves as a critical component of the comprehensive assessment process. Feelings of guilt and shame often accompany thoughts of burden commonly shared by sandwiched caregivers, so the likelihood of the couple openly communicating these feelings is slim. Relatedly, for example, a great deal of anger or frustration with the deceased individual is often overlooked by clinicians when working with individuals dealing with spousal bereavement. Therefore, a skilled clinician seeks opportunities to fully explore interpersonal dynamics associated with this oft-concealed caregiver distress for either one or both members of the couple. This process, while informative, is typically

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not geared toward identification of individual psychological disorders, but rather is focused more on the information surrounding interpersonal dysfunction and is thus critical to the process of creating a successful treatment plan. To further assist in the assessment of clinically significant individual and collective (i.e., couple) concerns related to sandwiched couples and spousal bereavement, several instruments are recommended. Sandwiched Couple Instruments Clinical assessment of couples can provide a wealth of relevant clinical information that can be utilized to inform treatment. Additionally, one often understated benefit of couples assessment is the information that can be gleaned from blatant discrepancies between how members of the couple view or respond to the same life events and stressors. This holds true particularly for couples dealing with stage of life issues. The Perceived Stress Scale (Cohen, Kamarck, & Mermeistein, 1983) provides a short, cross-culturally normed measure of recent (i.e., previous month) perceptions of stressrelated symptoms. This instrument can prove useful in the assessment of both sandwiched couples as well as in cases of spousal death due to the scale’s ability explore the perceived stress response to the life-changing event. At only 10 items, the Perceived Stress Scale is practical and can easily serve as a component of a comprehensive assessment battery. The Couples Satisfaction Index is a 32-item self-report measure of individual perceptions of marital satisfaction in a relationship (Funk & Rogge, 2007). While self-report instruments can be problematic due to concerns with both social desirability and various cognitive biases (e.g., projection bias or rosy retrospection) in the validation process, these instruments can be invaluable in couple therapy as they provide clinical clarity regarding the couple’s mutuality of perceptions, attitudes, and beliefs. The Perceived Support Scale (Krause & Markides, 1990) has been utilized to explore perceptions about support for the caregiving role. As higher levels of perceived support have been correlated with better caregiver health (Pinquart & Sorensen, 2011), higher levels of caregiver satisfaction, and lower levels of self-reported stress (Haley, LaMonde, Han Burton, & Schonwetter, 2003), it is imperative to explore couples’ individual perceptions of caregiver support. Discrepancies between caregivers may be an indication of other individual psychological distress (e.g., negative cognitive schemas or the existence of mood or anxiety disorders) or perceived spousal commitment to the caregiving function itself. Spousal Bereavement Instruments Bereaved partners may benefit from assessment batteries that explore reasonable symptoms of grief and loss such as depression, anxiety, and various

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coping scales. However, several instruments purport to measure specific characteristics of spousal bereavement and may prove useful in working with couples who have experienced this type of loss. A couple of noteworthy instruments that capture common symptoms of spousal bereavement are the Inventory of Traumatic Grief and the Grief Experience Inventory. Additionally, for bereaved spouses, the Continuing Bonds Scale measures perceived ongoing bond with the deceased partner, and the Continuing Bonds in Coping Scale measures the level to which bereaved partners utilize continuing bonds as a mechanism to cope with the grief. Minton and Barron (2008) provide an informative summary of assessment tools that can be used with clients suffering from bereavement. Cultural Considerations and Suggestions for Culturally Competent Practice For clinicians, consideration of cultural factors when working with couples is critical to therapeutic success. This is particularly true when working with couples immersed in stage of life issues. Individual members of couples enter into relationships with a multitude of identities taking precedence in varying degrees depending on the individual’s developmental factors (e.g., life stage) and the interaction with social factors (e.g., caregiving for an elderly parent or financial hardship). In the clinician’s effort to engage in culturally competent practice, a clear focus on the couple’s sociopolitical history, cultural worldviews (i.e., including views on race, gender, and other cultural factors), cultural identity development, and the interplay between the clinician’s and couples’ identity development is key to promote successful therapeutic outcomes. The clinician may be justified to focus more heavily, particularly in early sessions, on gender identity and gender role expectations, as these factors tend to assist in developing a comprehensive couple case conceptualization. This recommended focus, however, does not suggest that other cultural factors are less important or valuable to the conceptual understanding, but rather that the focus on gender role expectations may be of more benefit to the therapeutic process toward the beginning. Case Example: Lucinda and Ron At the advice of a fellow church member, Lucinda and Ron sought therapy for the first time in their nearly 40-year marriage. The couple reported that they recently realized that they both regret getting married. According to Lucinda, they had “bends in their relationship before, but were now at the point of breaking.” Ron, a retired truck driver in his late 60s, and Lucinda, a retired school teacher, had traditionally sought assistance from their longtime church pastor. Since the pastor’s death a few years prior, they have not

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seen anyone regarding their relationship concerns. Neither presented with a previous history of counseling or psychotropic medication treatment. They reported having periodic relationship distress over the years, but stated that it was “nothing out of the norm for a marriage.” Lucinda claimed that she made the appointment because the couple was at their “wits end” and that their marriage was near a “point of no return.” Lucinda and Ron had two children, both now in their mid- to late 30s. Their daughter, the youngest, lived within a 15-minute drive from their home, and they reported their relationship with her to be strong. “She’s the one bright spot we have,” reported Lucinda. They reported visiting with their daughter and her family as often as schedules would allow. Their oldest, a son, was the father of three children ages 12, 6, and 4. He had a long, troubled history of alcohol and drug abuse and had been in and out of detox, residential treatment, and jail. He lost his driver’s license in his mid-20s due to obtaining numerous Driving Under the Influence (DUI) charges over the years, and Ron and Lucinda expressed an obligation to “make sure he gets where he needs to go.” They voiced concern that he would drive illegally if they refused to chauffer him when requested. As an estranged father, he has depended on Lucinda and Ron to provide transportation when his children visited throughout the year. During the previous decade, reported Lucinda, the couple has been “forced” to take on more of a parental role than they would like to with their grandchildren. During the diagnostic interview, Ron remained fairly quiet, yet he would show periodic signs of agitation when certain interview topics arose. While the couple expressed that they did not have a specific reason for pursuing counseling at this time, the discussion of family history, and particularly their son’s history, seemed agitate Ron. Typically unresponsive, he would bristle, sigh, and verbally “harrumph” as Lucinda spoke of their son. When explored, it was discovered that the younger two children recently began living with the couple along with Lucinda’s 90-year-old mother who suffers from Major Neurocognitive Disorder, Dementia. Upon further inquiry, both expressed significant distress from their added caregiving responsibilities and frustration with one another due to a perceived lack of appreciation for their respective individual sacrifices. Lucinda was appropriately dressed, polite, and eager to begin the session. She was detail-focused and often recounted specifics about situations without acknowledgment of any emotion. She stated that “things had to be done in order to keep her family together” and, likely as an expression of the resentment she held toward Ron, stated that “someone had to step up and care for the kids.” She was easily moved to tears when discussing her son and his shortcomings as well as the recent caregiving role for his children. She moved fluidly from politeness to combativeness toward Ron depending on the topic of inquiry and often apologized to the therapist after noticing when she raised her voice during the session.

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Ron was, for the most part, a reserved man. He, unlike Lucinda, wore his emotions openly. Without saying a word, it was clear when he disagreed with something being said. He would regularly cross his arms or shift in his seat when he became mildly frustrated and often let out a verbal grunt or growl when he wished to interject something into the session. Assessment Considerations The couple completed a full diagnostic assessment during the first session to assess biopsychosocial functioning along with the couple’s diagnostic and treatment history. Revelations surrounding the recent significant life changes prompted the clinician to conduct a comprehensive assessment battery in lieu of the couple’s second scheduled session. The Perceived Stress Scale (Cohen et al., 1983) was utilized to measure individual perceptions of stress during the previous month. The Perceived Support Scale (Krause & Markides, 1990) was used to measure perceived social supports for caregiving functions. For purposes of couple therapy, large discrepancies between individual partners on individual items or subscales could serve as a direct indication of triggers or other sources of interpersonal conflict. Ron Ron grew up the younger of two boys in a small, rural Midwestern town. Ron reported that he did not grow up in a household that demonstrated much affection or nurturance. He and his brother, two years his senior, often teased and ridiculed each other mercilessly. “That was how we showed our love for one another,” according to Ron. Ron’s father rarely held steady employment and spent much of his time as a temporary hired farm hand or completed other “odd jobs” around town to help with the family’s finances. Ron’s mother, on the other hand, often worked two jobs as a factory worker and part-time maid. The discrepancy between the perceived work ethic and financial contribution of Ron’s parents was often a source of contention in his household growing up. “They argued constantly about money,” stated Ron, “to the point where I knew I had to get out and get a job to help support myself.” Immediately after high school graduation, Ron enlisted in the Army. He reportedly struggled through basic training and claims that he “washed out” after only two years. Ron then returned home and applied at the trucking company where he was employed for 37  years. Ron officially retired from the company five years ago, but has continued to drive nearly half-time since Lucinda’s mother and his two grandchildren moved in. “We need the money,” he exclaimed while discussing his frustration with working after retirement. Ron presented with clear and unabashed gender role expectations during the first few sessions. He stated that he did not have any qualms about taking in Lucinda’s mother, but he expressed more hesitancy about taking

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in the children. “Our son is about as worthless as they come,” he stated. Ron recounted Lucinda’s involvement in his mother’s care in the last few years of her life. He expressed appreciation for Lucinda taking the role of primary caretaker, yet he was clear that this was something that he expected from his wife. Additionally, he was clear in his expectation that Lucinda would take on the primary child rearing function and caregiving function with their current living situation. He succinctly concluded, “Well, she’s their grandmother and her daughter, isn’t she?” For his own reflection, Ron saw himself primarily as a financial contributor to the household. During their marriage, he rarely spent any of his earnings on personal interests, but rather passed his paycheck along to Lucinda to manage. Lucinda Lucinda, a self-proclaimed loner as a child, was born to a family of nine children. Her father was approximately 20  years her mother’s senior and had two grown children prior to his involvement with Lucinda’s mother. Her mother, only 17 when she met Lucinda’s father, had one child from a previous marriage. “Her first husband died in the war,” stated Lucinda. She expressed admiration for her mother’s strength as she reflected on her mother as a young widow. “She always took good care of us . . . of family,” Lucinda expressed. While Lucinda lauded her mother for her dedication and loyalty to the family, she openly discussed her yearning for more interaction with her parents growing up. Since her mother’s initial diagnosis, Lucinda was eager to take on an increased caregiver role. Lucinda frequently expressed frustration with Ron’s apparent disgust with their son. She often used the word “disease” to discuss her son’s alcohol and drug abuse. She often became emotional when discussing their son and made overt attempts to redirect these conversations back to issues she had with Ron. She perceived Ron to “check out” when dealing with familial concerns and stated that she wished that “Ron would be present sometimes . . . I mean, he’s physically there, but not mentally or emotionally.” Lucinda initially refused to acknowledge the added burden of caring for her aging mother and grandchildren; however, as therapy progressed, she more readily expressed her concerns and distress regarding her newfound situation. “I never thought this is how retirement would look,” she joked. DSM-5 As a result of the diagnostic intake and interview, Ron’s symptoms met DSM-5 criteria for Adjustment Disorder With Depressed Mood. As the couple confirmed that he demonstrated no mood disturbance prior to the lifestyle-altering living situation, it was determined that the Adjustment Disorder served as the least stigmatizing diagnosis necessary to warrant effective

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treatment. Lucinda, per the couple report, met diagnostic criteria for Generalized Anxiety Disorder prior to seeking treatment. She also demonstrated symptoms of Adjustment Disorder as a result of the recent changes in the family structure. Her Adjustment Disorder diagnosis included the With Mixed Anxiety and Depressed Mood specifier. The couple collectively met DSM-5 criteria for Relationship Distress With Spouse or Intimate Partner as an “other condition that may be the focus of clinical attention.” Case Conceptualizations: Individual and Couple Individual Case Conceptualization Lucinda’s recent persistent frustrations with her relationship are a likely manifestation of her beliefs about marriage, her meaning-making structure, systemic/societal gender role expectations and conflict therein, and/or her unconscious object relations placed on the caregiver/security role. Cognitively, she expressed numerous dysfunctional beliefs regarding her role as a caregiver and as a wife. For example, she held strong to the belief that Ron should show more interest in their son’s well-being. The 41-year-old was recently kicked out of a treatment facility, and Ron was reluctant to offer him the couch in their home. She saw this as an affront to both their marriage (i.e., “if Ron doesn’t care about her son, then he couldn’t possibly care about her anymore”) and her perception of him as a father (i.e., “he’s not the father I thought he was”), which is a characteristic she previously admired. Her dysfunctional thoughts, when not checked, had the potential to lead her down a “rabbit hole” of unfounded conclusions. From a meaning making perspective (e.g., existential–humanistic or constructivist), Lucinda struggled with connecting with her authentic or congruent self. At her core, she cared deeply about whether and how she was valued by those she loved. She was resentful of her son’s behavior, her perception of her husband’s disinterest and lack of support, her siblings’ lack of support with the care for her mother, and her daughter’s lack of involvement with the recent family dynamic. While she outwardly expressed a sense of purpose for the daily task of caring for others, she felt perpetually unfulfilled. She was stuck in a void of meaning that led to a constant feeling of unrequited obligation and burden. Her avoidance or unawareness of her personal responsibility and choice prohibited her from owning her situation. These things, in her mind, were happening “to” her rather than her choosing them. She needed to recognize her power to self-define as a caregiver rather than be forced (i.e., victimized) to serve in her caregiving function. Lucinda can be conceptualized via a multicultural or feminist therapeutic lens by exploring her perceptions and meaning through the framework of examining societal gender role expectations. She would benefit from acknowledgment of her perceived role in the social order. Her resentment

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toward her husband may, in part, be a displacement of her frustration for how she believes she is expected to behave. Similar to the meaning-making theories, she would likely benefit from a realization that she can choose to either accept or reject the gender role expectations rather than be beholden to them in a blanket fashion. From a psychodynamic perspective, Lucinda likely struggles with relationships due to her yearning for a sense of security. This search for secure bonds presents a paradox for this client as she likely seeks out individuals who are seemingly unwilling or unable to demonstrate the kind of unwavering positive valuation she seeks. Therefore, her husband through his inability, her mother through her neurocognitive disorder, her son through his selfishness and addiction, and her grandchildren through their youth are all destined to “fail” her in this regard. To Lucinda, to capture the positive appraisal of the “unreachable” allows her to fulfill a burning desire from her own childhood. Ron’s outward portrayal of frustration and periodic expressions of apathy are often nothing more than thinly veiled attempts to mask his disappointment and despair. His symptoms are likely representations of his cognitive schemas, meaning-making structure, gender role expectations and the conflict therein, and/or unconscious object relations placed on common familial roles. His cognitive expectations are indicative of both “black and white” thinking from a cognitive–behavioral perspective and patriarchal privilege from a systemic/societal perspective. As his societal conditioning, similar to Lucinda, likely shaped his cognitive functioning and perspectives, Ron exhibits significant difficulty challenging his beliefs even in the face of clear and irrefutable evidence to the contrary. From an existential–humanistic perspective, Ron values the principle of marriage. While he finds his current situation to be taxing, he finds meaning in his ability to provide for members of his extended family. He finds significant distress in his inability to reconcile his identity as a retiree with his newfound role as caretaker. To him, a caretaker provides . . . nothing more, nothing less. In his myopic view of his role, however, he still finds significant meaning in the way in which he believes Lucinda views him. He legitimately cares that she is malcontent with their current living situation. “I wanted her mother to move in with us to please her (Lucinda),” he stated. “I thought it would make her happy.” Ron’s struggles with nurturance and affection served as ample kindling for his self-doubt, internalized blame, and self and other criticism to flourish once he perceived adversity in his marriage. He teased and verbally sniped at his wife in the same manner as he was accustomed to as a child with his older brother. He was uncomfortable with Lucinda’s affective expression while simultaneously making every effort to hide his own emotional distress out of fear being shamed by his partner. He would rather suffer in silence than

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appear vulnerable; vulnerability, in his mind, gives credence to his unworthiness to be nurtured. Couple Case Conceptualization Lucinda and Ron presented with desperation. While they certainly had interpersonal concerns to work through, they gave little consideration to the notion that the recent changes to their living situation had any effect on their marital discord. Instead, they allowed their maladaptive adjustment to manifest itself as a means to express the depth of criticism and resentment they felt for one another. Where couples typically allow their episodic frustration to show itself during arguments and other tiffs, Ron and Lucinda’s recent prolonged distress associated with added responsibility, changes in identity, and overall lifestyle modification served as a prime opportunity for them to become hypercritical of their relationship. Instead of questioning their recent life choices, they were content in denying that they had choice. The only choice, therefore, was whether they would continue their relationship. Lucinda’s anxiety about her own worthiness combined with Ron’s tendency to barricade himself emotionally served as a “perfect storm” bent on decimating their 40-year marriage. If, through therapy, they could find meaning, alignment, and a unified purpose in their decision to take on caregiving responsibilities for Lucinda’s mother and their grandchildren, then they could successfully begin to take stock of their marriage and where they wanted it to go. Cultural Considerations Ron and Lucinda both identify as rural, Midwestern, and white. While they have regularly attended the same Baptist church for nearly four decades, Ron reports attending mainly due to Lucinda’s urging in the past. “It’s something she wants me to do,” he explained. As part of her rural upbringing, Lucinda is hyper-reflective about how she perceives others’ views about her family, and couple, dynamics. She has spent countless anxiety-ridden hours fretting over what members of her community will think about their troubled son, their evaluation of her performance as a mother and wife, and how they view her sacrifices as a caretaker. Ron is also aware of his perceptions of these critiques, yet his response reflects takes a much more defiant tone. “He knows that everyone is talking,” exclaimed Lucinda, “but he doesn’t care how we’re viewed . . . how our name is run through the mud.” In many rural communities, residents will often take great collective pride in their adherence to traditional beliefs and values. These traditional beliefs and values typically encompass a wealth of individual and group identities. Gender identity and corresponding gender role expectations are no exception, as they often reflect a more traditional, patriarchal-dominant status quo. Lucinda and Ron were both raised (i.e., conditioned) in an environment

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that heavily rewarded the promotion of patriarchal ideals and practices and, thus, have internalized many of these beliefs as their own. During treatment, Lucinda expressed guilt over questioning if she was betraying her upbringing by expressing her need for Ron to take on more (i.e., support) of a caregiving role for her mother and the grandchildren. Treatment Considerations Several key treatment considerations are warranted in working with Ron and Lucinda. First, the couple must effectively explore the attitudinal structures (cognitive, affective, behavioral) present within their relationship in order to promote healthy and effective communication and promote a collective sense of purpose both as a couple and as caregivers. As part of the cognitive exploration, the promotion of awareness of the couples’ gender role-based cognitive expectations will help to bring their decisions into consciousness and allow for increased intentionality and accountability. Additionally, Ron and Lucinda would benefit from making efforts to refocus on their coupling, at least to levels present prior to the decision to take on the collective caregiving role. Individual and conjoint therapy are recommended to allow considerable time and adequate space to work through both individual and collective issues related to the life-change. During individual therapy, significant focus on pre-existing anxiety, cognitive dysfunction, individual purpose and meaning, and developmental concerns are warranted. Conjoint therapy will likely include additional focus on collective purpose, activities, and explorations geared toward refocusing on the couple, collective identity, and building effective communication, coping, and assertiveness skills as a couple. Conclusion: Summary of Recommendations for Working With Couples While there are certainly intrapsychic characteristics that make certain individuals more likely to feel compelled to take on numerous simultaneous caregiving roles, the act of providing care for loved ones should not be viewed as pathological. While literature suggests that sandwiched caregivers are more likely to suffer from psychological distress along with a host of other potential issues, the effect of sandwiched caregiving on the couple remains to be determined. Common sense, along with anecdotal evidence, suggests that, if left untreated, sandwich couples are at risk to suffer in the same manner as their individual members and that coupling fails to serve as a safe haven for the deleterious effects of sandwich caregiving. Concurrently, spousal bereavement has the potential to cause significant distress and impairment in functioning if not effectively treated. When capable, it would behoove clinicians to take a multipronged approach to treating both issues, as it is believed

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that each has the respective capability to serve as a trigger for a pathological (i.e., leading to impairment in functioning) response. Therefore, it is recommended that sandwich caregiving and, when available, spousal bereavement be treated in both a preventative and responsive manner in order to promote the most comprehensive approach possible. Preventative care could include anticipatory psychoeducation with hospice and palliative care spouses to promote coping strategies and begin treatment with death anxiety. Additionally, preventative couple therapy could explore death anxiety as a general component of affective and cognitive examination. With sandwich couples, a preventative clinical lens, on the part of the therapist, may alert the clinician to explore meaning and purpose, cognitive expectations, and behavioral fit with couples long before they decide to take on additional caregiver roles. With commitment, preventative treatment modalities could serve as a successful early intervention with the intention of prompting bereaved spouses and sandwich caregivers into a treatment protocol where much of the therapeutic groundwork has already been established. References American Psychological Association. (2011). Resolution on family caregivers. Retrieved January  13, 2018, from www.apa.org/about/policy/family-caregivers. aspx American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing. Backhouse, J.,  & Graham, A. (2013). Grandparents raising their grandchildren: Acknowledging the experience of grief. Australian Social Work, 66(3). doi:10.108 0/0312407X.2013.817595 Boyczuk, A. M., & Fletcher, P. C. (2016). The ebbs and flows: Stresses of sandwich gen­ eration caregivers. Journal of Adult Development, 23, 51–61. doi:10.1007/s10804015-9221-6 Buffardi, L. C., Smith, J. L., O’Brien, A. S., & Erdwins, C. J. (1999). The impact of dependent-care responsibility and gender on work attitudes. Journal of Occupational Health Psychology, 4, 356–367. Cohen, S., Kamarck, T., & Mermeistein, R. (1983). A global measure of perceived stress. Journal of Health and Social Behavior, 24, 386–396. Dobson, J. E., & Dobson, R. L. (1985). The sandwich generation: Dealing with aging parents. Journal of Counseling and Development, 63, 572–574. Doley, R., Bell, R., Watt, B., & Simpson, H. (2015). Grandparents raising grandchildren: Investigating factors associated with distress among custodial grandparent. Journal of Family Studies, 21(2), 101–119. doi:10.1080/13229400.2015.1015215 Funk, J. L.,  & Rogge, R. D. (2007). Testing the ruler with item response theory: Increasing precision of measurement for relationship satisfaction with the Couples Satisfaction Index. Journal of Family Psychology, 21, 572–583. Haley, W. E., LaMonde, L. A., Han, B., Burton, A. M., & Schonwetter, R. (2003). Predictors of depression and life satisfaction among spousal caregivers in hospice: Application of a stress process model. Journal of Palliative Medicine, 6, 215–224.

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Hammil, S. B. (1994). Parent-adolescent communication in sandwich generation families. Journal of Adolescent Research, 9(4), 458–482. Krause, N., & Markides, K. S. (1990). Measuring social support among older adults. International Journal of Aging and Human Development, 30, 37–53. Minton, M.,  & Barron, C. (2008). Spousal bereavement assessment: A  review of bereavement-specific measures. Journal of Gerontological Nursing, 34, 34–48. Montgomery, J. V., Stull, D. E., & Borgatta, E. F. (1985). Measurement and the analysis of burden. Research on Aging, 7(1), 137–152. National Alliance on Caregiving. (2005). Young caregivers in the U.S. Retrieved January 12, 2018, from www.caregiving.org/data/youngcaregivers.pdf Newman, B. M., & Newman, P. R. (2014). Development through life: A psychosocial approach (12th ed.). Stamford, CT: Cengage Learning. Ott, C. H., Lueger, R. J., Kelber, S. T., & Prigerson, H. G. (2007). Spousal bereavement in older adults: Common, resilient, and chronic grief with defining characteristics. Journal of Nervous and Mental Disease, 195(4), 332–341. doi:10.1097/01. nmd.0000243890.93992.1e Pinquart, M.,  & Sorensen, S. (2011). Spouses, adult children, and children-in-law as caregivers of older adults: A meta-analytic comparison. Psychology and Aging, 26(1), 1–14. doi:10.1037/a0021863 Solberg, L. M., Solberg, L. B., & Peterson, E. N. (2014). Measuring impact of stress in sandwich generation caring for demented parents. The Journal of Gerontopsychology and Geriatric Psychiatry, 27(4), 171–179. doi:10.1024/1662–9647/a000114.

18 RELIGIOUS AND SPIRITUAL PROBLEMS IN COUPLES Steven J. Sandage, Chance A. Bell, Sarah H. Moon, and Elizabeth G. Ruffing

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eligion and spirituality (RS) can provide sources of support, meaning, and healing to help couples develop healthy relationships, but couples can also struggle with RS differences, conflicts, and contextual stressors that contribute to deep rifts (Walsh, 2013). In this chapter, we will consider the clinical implications of RS problems in couples, drawing upon a relational spirituality model that defines spirituality as “ways of relating to the sacred,” with the sacred meaning whatever a person considers ultimate or Divine (Worthington & Sandage, 2016, p. 38). In this model, “spirituality” is the broader construct and “religion” references relate to the sacred within the context of religious communities, practices, and traditions. This processoriented framework also assumes that relational forms of spirituality can range from the salutary to the pathological with respect to influences on relational functioning. We will first consider a heuristic taxonomy of some RS problems that can contribute to suffering among couples and then relate that taxonomy to the DSM-5. We follow this with a couple therapy case illustration, which we conceptualize based on the relational spirituality model. Overview: Theory and Research on RS Problems in Couples Arguably, there are RS differences within every couple, even if they subscribe to the same general RS orientation or tradition. But there are also indications couples are becoming increasingly diverse in RS dynamics, as interfaith marriages and intimate relationships have become much more common in the United States (U.S.) over the past 60 years. Prior to 1960, 19% of marriages in the United States were interfaith, including Christians with differing traditions (11%), a Christian and an RS unaffiliated spouse (5%), and mixed tradition marriages (3%). By 2014, the number of interfaith cohabitating and

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married couples had increased to 49% and 39% respectively (Pew, 2015). The latter percentage included Christians with differing traditions (15%), a Christian and an unaffiliated spouse (18%), and mixed tradition marriages (6%). We believe RS differences can be valuable sources of diversity within couple relationships; however, couples can struggle with differences related to their RS backgrounds or changes in RS dynamics that emerge over time. Below we explore nine common areas of RS issues within couple relationships. First, problematic RS differences between partners may involve couples’ differing RS backgrounds or evolving RS practices/preferences that may not be aligned and cause conflict. For example, one partner desires to attend religious services weekly with their children, but the other, not belonging to the same RS tradition, prefers to attend a differing RS congregation. Second, couples that experience losses may grieve in RS-discrepant ways that do not make sense to one another or that lead partners into completely separate RS coping processes following the loss (Ungureanu  & Sandberg, 2010). For example, a couple seeking to have children discovers they are infertile. One partner turns toward RS to cope with the sense of loss, and the other turns away from RS. Third, betrayals experienced as a desecration (or sacred loss) can strike at the heart of RS traditions and may feel like a violation of the sanctity of the relationship, making it difficult to collaborate in healing. For example, a spouse has an affair, and this betrayal of a sacred vow feels like a desecration to the other. Fourth, imbalances of power and control happen when RS dynamics are used by one partner to assert dominance over the other partner’s actions and to limit his/her influence on the relationship. For instance, a husband uses scriptural references to assert dominance over his wife and calls for her compliance to his demands, while she is not allowed to question his behavior. While gender-related imbalances of power and control are normative within certain RS traditions, there are cases where those imbalances lead to impairment in couple functioning. Fifth, acculturation challenges related to RS dynamics appear when a couple struggles to find RS resources within a new context. One example is a Hindu couple moving into a rural area in the United States that lacks an active Hindu community to support their RS practices. Sixth, couples may also engage in RS bypass or use of RS as a rigid defense mechanism to dismiss or avoid certain topics and issues within the relationship that are problematic due to RS principles/values/doctrines that seem to oppose openly facing problems and relational complaints. To illustrate, a couple is dissatisfied with their sexual relationship but are unable to discuss it because they believe their RS tradition teaches they should always be joyful and avoid “complaining.” Seventh, transgressions may prove difficult to forgive based on ways RS principles/doctrines are internalized through relational spirituality

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(Worthington & Sandage, 2016); thus, unforgiveness (i.e., revenge, emotional avoidance) may be perpetuated by certain RS dynamics. For example, one partner has an affair and contracts a sexually transmitted disease. The other partner believes forgiveness is impossible and feels abandoned by God, and this leads the first partner to despair about self-forgiveness and their own RS well-being. Eighth, RS intersectionalities can prove conflictual when RS aspects of identity for one or both partners conflict with other aspects of social identity. An example might be a Jewish gay couple where one spouse wants to attend a gay-affirmative congregation while the other considers religion inherently oppressive to LGBTQ communities. Ninth, RS discrimination or marginalization based on gender, race, ethnicity, RS tradition, sexuality, and disability can lead to suffering among couples. For example, a transgender couple is ex-communicated from a religious congregation due to their gender orientation. Although not exhaustive, this list provides clinicians a heuristic guide for recognizing potentially distressing RS categories for couples and is more expansive than the categories for religious and spiritual, and/or intimate relationship problems provided in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) (American Psychiatric Association, 2013). DSM-5 and Religious and Spiritual Problems The DSM-5 provides limited consideration of RS challenges. The religious or spiritual problems V-code (62.89) is appropriate when it is determined that the focus of clinical treatment will be challenges related to the RS of a client. Examples from the DSM-5 include problems related to questioning or loss of faith, conversion to new RS beliefs, and questioning values not necessarily part of organized religion. These kinds of RS questioning or change processes can be normal parts of human development but sometimes generate distress that leads to impairments in psychosocial functioning. Religious or spiritual problems may be an individual concern but can also impact couple relationships, as in the case below. Case Example: Craig and Jackie Craig (age 40; German/Anglo-American) and Jackie (age 32; Filipino-American, Filipino name Jovelyn) had been married nine years when they entered couple therapy. They met a year before their marriage when Jackie started attending the large, non-denominational, Evangelical Christian church where Craig was an associate pastor in charge of the worship team. She was in a stressful time of transition, working in sales at a retail store and also with her family’s landscaping business her mom and her four brothers were holding together following the death of her father. Her parents raised the family

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Catholic in the Philippines until they immigrated to the United States when Jackie was 12, but they converted to Evangelical Protestantism once in the United States. Jackie’s faith commitment intensified in her early 20s amid the grief and confusion of losing her father with whom she had been particularly close and relied upon for guidance. Upon meeting Craig, she was inspired by his confident faith and his charisma and talent as a musician. She was surprised by his interest in her and did not have much dating experience, but he was persuasive about their fit as a couple. Craig was drawn to Jackie’s quiet and calm demeanor, her obvious loyalty to family, and her strong work ethic. His parents voiced skepticism about Jackie, which he attributed to racism, and this served to intensify his motivation to marry her. Craig’s parents had immigrated from Germany to a small Midwestern town and raised Craig and his two brothers working in the family hardware store. Craig’s younger brother was tragically killed in a hunting accident that the family never openly processed. Craig’s older brother proved a natural and reliable fit for the family business. In contrast, Craig showed signs during his high school and college years of opposition to his parents’ structured expectations and the family norms of “not showing out.” He longed to leave the rural region of his hometown and nearby college, and his gifts in leading contemporary forms of worship provided a prosocial form of rebellion and, eventually led to a job in a major city. Craig and Jackie’s conflicts over RS started shortly before their wedding. Jackie had fallen and broken her wrist, and she became hurt over ways Craig seemed callous to her discomfort and physical limitations. On one occasion when she was at his apartment, he asked her to make dinner for him and berated her as “selfish” when she said she could not perform the task with one arm. This became part of an ongoing pattern of Jackie experiencing Craig’s impossible expectations followed by fits of his anger. Craig reported becoming stressed by Jackie’s cycling through periods of intense neediness (e.g., calling him multiple times per day crying or asking advice, wanting to talk late into the evening about worries about her mom and family, and asking him to skip church events to stay home with her). As Craig became more critical, domineering, and shaming, Jackie vacillated between anxiously trying to get approval or nurturance from him or pulling back into a protective shell. Following her father’s death, Jackie initially found great relief from a sense of God’s presence with her new RS community. Over time, her spirituality was characterized by an unarticulated anxiety about God’s commitment to her and possible disappointment with her, as well as fears that God would abandon her (like her father did). She poured herself into volunteering at the church, and becoming a pastor’s wife seemed guaranteed to gain the approval of God and people in the community. However, the community’s expectations of her were overwhelming, and her frustration at her inability to meet them turned into resentment and withdrawal. The church’s work

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expectations of Craig also felt unfair. He was often at the church multiple nights a week, and she began to describe the church leadership as expecting her to be the “happy helpmate” who assisted at events without remuneration. When she became depressed after their second miscarriage, she was shocked the elders told Craig it was “a bad witness to the congregation to have her looking so forlorn.” Their marriage temporarily improved when Craig had a major power struggle with the senior pastor and decided to leave the ministry to join his uncle in a business venture managing a new interior design company. The business took off and was enormously successful for several years, which offered the couple temporary economic security and allowed Jackie to start college. However, Craig proved better at drawing in new customers than managing his relations with employees, and his frequent intense conflicts at work eventually started to compromise the company’s ability to deliver on projects. His uncle fired him, which precipitated a major depressive episode over a sense of shameful failure and ambiguity about his vocation and their financial future. Jackie had started seeing a therapist after starting college and came to realize she had struggled with anxiety and perfectionism for many years, and she also began to process ways that grieving her father’s death had been complicated by cutting guilt she felt about the rare argument they had the day before he died that was left unresolved. Her therapist suggested the benefits of meditative practice to Jackie, and she eventually found a meditation class at a local Zen Center and began attending weekly Dharma talks and group events. She found meditative practice to be extremely helpful, and the intuitive, experiential emphasis of Zen philosophy seemed to help liberate her from a chronic sense of feeling “defective.” She enrolled in classes on Buddhism and also started reading books on Filipino folk religions, which coincided with intentional exploration of her cultural identity and the decision to go by her Filipino name of Jovelyn. She had not exactly rejected her prior Christian beliefs. But she was still disillusioned by their experiences at the church where Craig had worked, and Buddhist practice did not activate her lifelong worry about whether God really accepted her or not. Jovelyn’s spiritual changes toward RS hybridity re-ignited conflicts with Craig. In one heated argument, Craig called her a “heretic” and “spiritually lost.” Jovelyn, who often held back in arguments, countered,

Y

ou’re the one that is lost! What kind of Christian are you, anyway? You haven’t been to church in two years, you’re angry at everyone and absorbed in your own world, constantly feeling sorry for yourself. Don’t judge me . . . my spirituality is helping me. You abandoned yours when you got a little career success and now you think we both have to look like ‘good Christians’ for God to bail you out of the mess you created.

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Assessment Considerations Assessment procedures for this case first needed to attend to mental health symptoms (e.g., depression, anxiety) and personality dynamics, but we considered those within our relational spirituality framework, which assumes RS, intrapersonal, interpersonal, and cultural dynamics are intimately connected. Our relational spirituality approach targets developmental and systemic assessment of numerous factors, including physical safety and marital commitment (see Worthington & Sandage, 2016), but we will focus here on (1) attachment dynamics; (2) differentiation; and (3) RS struggles. Attachment Dynamics Research on attachment theory has established implications for couples’ relationships and also for individuals’ ways of relating to the sacred (Mikulincer  & Shaver, 2016), making the assessment of attachment styles important in our model. Research has shown that attachment styles in adult relationships often correspond to individuals’ styles of relational spirituality and perceived relationship dynamics with God or the sacred. A person who experiences a secure attachment to the sacred tends to feel safe, unconditionally loved, and experiences God or the sacred as a secure base for exploration. We use the concepts of spiritual dwelling and seeking to represent relational spirituality dimensions of safe haven and secure base attachment functions, respectively (Worthington & Sandage, 2016). A person who experiences an insecure spiritual attachment may have anxious or avoidant styles (or a disorganized combination of both). For example, narcissistic styles such as spiritual grandiosity, which has characterized Craig at points, might amplify the association between interpersonal and spiritual attachment tendencies and result in avoidant attachment dynamics of rigidity, superiority, and limited empathy (Sandage, Jankowski, Crabtree, & Schweer, 2015). For clients like this couple, who emphasize a “personal relationship with God,” a therapist can assess clients’ attachment style to God by noticing how they relate to God and also tuning into how they imagine God relating to them. This may include inquiring about how God sees them, God’s posture toward them, God’s emotions toward them, and so on. For clients who come from nontheistic traditions or where the sacred may seem less explicitly relational, it is possible to assess attachment-laden experiences of abandonment, withholding, disappointment, security, compassion, and other relational themes that they may experience in connection to whatever they hold sacred. It is particularly helpful when there are parallels that can be drawn between an individual’s dynamics of relational spirituality and ways they relate with their spouse, but significant differences in those relational dynamics might also reveal important psychological dynamics. Clinicians can refer to the Experiences in Close Relationships scale (Brennan, Clark, & Shaver, 1998) and the

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Attachment to God scale (Rowatt & Kirkpatrick, 2002) for additional assessment language and resources. Differentiation Differentiation of self (DoS; Schnarch, 2009) also has important implications for a couples’ relational spirituality. DoS refers to the ability to balance (1) autonomy and connection in relationships and (2) cognitive and emotional functioning in ways that facilitate self-regulation (Worthington  & Sandage, 2016). High levels of DoS within a couple provides the space for partners to grow and change spiritually over time, and it also enables couples to connect in the presence of spiritual differences or changes rather than being reactive or avoidant. Poorly differentiated couples cannot tolerate the anxiety produced by encountering difference—rather, they are fused in such a way that they resort to avoiding the anxiety of difference at all costs, forestalling conscious awareness of any development that may imbalance the relational homeostasis. This leads to cutting off parts of themselves from their partner if they produce tension, or they become highly reactive to changes they see in the other. Partners may engage in spiritual seeking over time, at times in response to loss or life transitions (as with Jovelyn), and this will challenge the differentiation in the couple system. For couples like the one in this case, it can be important to assess the specific anxieties or concerns for each related to RS differences and how this might relate to basic commitment issues in their relationship. The Brief Differentiation of Self Inventory (Sloan & van Dierendonck, 2016) is also a helpful resource. RS Struggles When individuals consider their marriages to be sacred, it can be a source of increased commitment and resilience (Stafford, 2016), but it can also add a layer of complexity and distress when that bond is violated or threatened. Difficult life events can be experienced as a sacred loss or desecration, a factor that is associated with higher depressive symptoms in both religious and non-religious individuals (Pargament, Magyar, Benore, & Mahoney, 2005). Losses activate the attachment system, so important associations between losses, anxiety, attachment templates, and relational dynamics of spirituality can be anticipated. The couple in this case has had numerous losses, which have overwhelmed their relational capacities to support each other and remain spiritually connected in their struggles. They had also lost a church community they initially found supportive but later problematic, and they had drifted from any shared RS community into individualized approaches to coping—Jovelyn looking to individual therapy and a Buddhist community and Craig focusing on work and cutting off from RS community.

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RS practices should also be assessed, as a common practice such as prayer may have numerous meanings and functions within an individual and couple. For example, prayer can help a person have more compassion, forgiveness, and commitment to a partner (Fincham, Beach, Kaslow, Mahoney, & Cano, 2014) and foster adaptive emotional regulation (Ferguson, Willemsen, & Castañeto, 2009). Prayer could also function as a triangulating move of withdrawal from the relationship or of gaining power through a spiritual one-up move or a divine alliance against the other (Brelsford, 2011). A therapist should not assume one meaning but rather assess for its particular role, meaning, and function of RS practices. DSM-5 Jovelyn and Craig met criteria for V-codes of religious or spiritual prob­­ lem (V62.89) and relationship distress with spouse (V61.1). Jovelyn also met criteria for Generalized Anxiety Disorder (300.02), and Craig met criteria for Major Depressive Disorder, Single Episode, Moderate (296.22). Using the dimensional approach to personality functioning in DSM-5, Craig also showed impairment related to traits of negative affectivity and antagonism. Case Conceptualization This couple struggled with contrasting styles of insecure attachment that eventually compromised their abilities to (1) cultivate consistent closeness and intimacy; (2) connect and collaborate during times of stress, transition, and loss; and (3) relate in differentiated ways amid their differences in relational spirituality. Jovelyn’s perfectionistic ambivalent attachment style is historically evident in her dynamics with Craig, her family of origin, and her ways of relating to God, which have each involved tendencies to view herself negatively and to idealize others, to consistently feel anxiety about approval and emotional availability, and to hold deep insecurity about her own perspectives and competence. We say “historically” because her individuating moves of going to individual therapy and engaging in spiritual seeking and change contributed to some emerging attachment security and self-identity, though she has needed to use emotional cutoff from Craig to make this progress. Prior to this, her disappointment in her marriage and the miscarriages felt like a “sacred loss” (Pargament et al., 2005) of the roles of wife and mother that were emphasized in her community as her primary “calling” and as a sign of God’s favor. She had grown overwhelmed by feelings of abandonment by God, anger at God, and anxiety that her anger at God would lead to further abandonment by God. Craig had developed a narcissistic style of avoidant attachment characterized by low vulnerability and empathy, which meant he was unequipped to attach with Jovelyn in her grief and their shared stressors. He had used

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his intelligence, charisma, and powerful rhetorical abilities to gain the upper hand in relationships and to manage his significant need for validation from others. However, these strategies proved maladaptive over time when his success and the associated validation declined and his affective instability and antagonism led to intense conflicts and cutoffs in all his important relationships (including with God). Distancing from close relationships had previously worked to some extent when he disengaged with family to pursue ministry and marriage, and also in a second phase when he left behind conflicts in ministry for a new business career. But his most recent career failure had revealed his internal emptiness and his need to develop healthier interpersonal capacities. He had typically feared engulfment by the needs of others, but in his current state he was afraid of being abandoned by Jovelyn, who remained his last significant attachment. From a systemic perspective, this couple suffered from underlying dynamics of fusion, which allowed little tolerance for difference but had temporarily worked within (1) a shared RS orientation and (2) the complementary relations of Jovelyn idealizing Craig and Craig offering her a sense of guidance and new RS community beyond her family of origin. However, during stressful times and within those fused dynamics, they either had painful conflicts or distanced into emotional cutoff to reduce the anxiety of actual differences. With Craig finally in a vulnerable state of desperation, he felt an anxious need for support from Jovelyn and could no longer ignore her RS and other changes, but he also lacked the differentiation of self (DoS) to respectfully engage her as an equal adult partner. Jovelyn was confronted with the need to decide whether she was willing to try to integrate her personal changes into her marriage (which would require more DoS) or continue on a path of disengaging herself from her marriage. Cultural Considerations This case has various cultural dynamics that therapists should consider when working with this couple. Differences in RS dynamics may be more obvious with this couple, but an exploration of racial/cultural differences should also be incorporated into work with this couple, as both may be significantly influencing their marriage. The Developmental Model of Intercultural Sensitivity (DMIS) (Bennett, 2004) is a model that we utilize within our relational spirituality framework to assess intercultural dynamics. The DMIS posits that people have particular orientations toward cultural similarities and differences, ranging from an ethnocentric to an intercultural mindset. Across this spectrum are six orientations: Denial, Polarization, Minimization, Acceptance, Adaptation, and Integration. One of the goals in our approach to couples work is to help each person refrain from denying, defending against, or minimizing cultural

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differences by developing capacities to interculturally adjust their perspectives and behaviors toward an interculturally empathic mode of being in relationship, which requires high levels of differentiation. An important theme to consider about Jovelyn is her historical context as an immigrant from the Philippines. The history of colonization in the Philippines has had numerous effects on Filipinos, and considering how similar dynamics of colonizing or “Westernizing” may be playing out in the dynamic between the couple would be important. For example, how much has she been overly adapting or accommodating to the white male, Western perspective of Craig? How much of her identity is rooted in being able to accommodate? Although Jovelyn’s cultural strengths may include adaptability, flexibility, and family values, we must pay close attention to whether this leads to a lack of DoS and imbalances in power and control related to RS and other dynamics that may not be helpful for their marriage. It would also be important to understand her recent shifts in more conscious exploration of her cultural identity and new ways that are shaping her perspectives and values. Craig’s German-American ethnicity may influence certain cultural values and patterns that generally fit within stereotypical white male norms in the Midwest, but therapists should also (1) be careful about overuse of stereotypes and (2) consider the ways his social and historical context may impact and/or limit the way he brings himself forward in the marriage. Traditional German values of hard work, rationality and emotional containment, and husbands being the primary financial provider in the family might make his role more complex as their changes have unfolded (Winawer & Wetzel, 2005). He has his own struggles around loss, with both the loss of his brother and the loss of his professional and religious identity, which may be further limiting his emotional availability in their marriage. As a second-generation immigrant, it would also be important to understand the geographical losses and acculturation processes for Craig and his family and to explore similarities and differences with that of Jovelyn and her family. Craig will have benefitted from racial privilege, but for white immigrants to the U.S. this sometimes contributes to a disjointed social experience of fitting into the dominant racial group but not necessarily feeling connected or understanding the subtleties of cultural norms. The fact that Craig resisted his parent’s racism and married a person of color does not mean he has reflected deeply on his own racial and cultural identity or considered privilege and power dynamics in his marriage. The therapist should also manage their own countertransference to avoid idealizing Jovelyn’s perspective or working from a framework that may privilege Western ways of thinking and behaving. It is important to also note the critiques about utilizing attachment and differentiation as constructs to conceptualize individuals, couples, and families from non-Western contexts. In Jovelyn’s culture, self-reliance, autonomy, and exploration of individual

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identity may not be as important, whereas interdependence, collectivism, and closeness may be highly valued (Tummala-Narra, 2016). Therapists should not prematurely interpret Jovelyn’s behaviors as undifferentiated or high anxiously attached without careful assessment across contexts. A parallel temptation might be to rapidly push Craig toward emotional processing and relational closeness without appreciation for his cultural background. Treatment Considerations We summarize here our relational spirituality model of couple therapy (also see Worthington and Sandage 2016), which follows an iterative process moving through phases of: (1) forming an attachment; (2) co-constructing a developmental crucible; (3) processing disappointment and grief; and (4) cultivating and extending differentiation. (Note: Craig also started individual therapy early in the process that helped him do focused work on affect regulation strategies, self-identity, and family-of-origin dynamics. Both partners signed releases to systemically coordinate individual and couple therapies). Forming an Attachment Based on our relational approach to couple therapy, we consider a constructive therapeutic alliance to be a primary source of gain and conceptualize this process as forming a secure attachment with the couple system. Initially, this often involves negotiating collaborative agreement about the goals and tasks of therapy with each partner, and the emotional bond aspects of the alliance will tend to develop over time. In this case, it was important to assess commitment dynamics and whether both Jovelyn and Craig were committed to working on their marriage or if they needed to sort through ambivalence about remaining married. It is not uncommon for RS values to influence views of divorce, and clients can have differing kinds of concerns about positive or negative biases their therapist holds about divorce. The therapist in this case clarified that his role was not tell them to stay married or to divorce but to help each explore their integrity in arriving at decisions about how to proceed. Within two sessions, both had decided they wanted to make a good faith attempt to improve their marriage and would commit to the work of couple therapy for six months. Developing a secure attachment with both partners in couple therapy requires a difficult balancing of empathy and alliance-building with both persons rather than consistently siding with one. This systemic stance of multi-directed partiality means trying to communicate understanding of each person’s perspectives, desires, and goals. This requires high levels of DoS in the therapist and the ability to re-position when the pulls for triangulation intensify. In one early example of this, Craig, seemingly anxious about whether the therapist might be in Jovelyn’s corner on RS issues, asked, “So

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what is your religious orientation?” Recognizing the triangular nature of the issues, the therapist replied:

Y

ou know, that is such a sensitive area between the two of you, I am not sure it would help to have me share that at this point. I’m often willing to talk about my values, but you two are painfully locked in conflict over religion and telling you my own religious orientation won’t resolve that. I am committed to being fair to both of you on these issues and seeing if we can understand what is important to each of you on these matters.

This intervention would not satisfy all clients, but in this case, Craig softened his suspicion and mistrust and the session moved forward. In another tricky triangulation situation in session six, a discussion of RS beliefs led the therapist to follow up on a passing comment Craig made about the death of his brother. This quickly opened up in Craig a pocket of intense sadness, grief, and crying, which was surprising to Jovelyn. Her own insecurity and shame kicked in and she commented, “I guess I really suck as a wife. I asked about that many times and he never cried with me like that.” This was an example of the low differentiation that is common in couple systems early in therapy, which means clients will often make triangular comparisons between themselves and the therapist as the therapist starts to build an attachment with the client. In this case the therapist responded:

O

h, Jovelyn, I don’t think that’s a fair comment about you or your marriage. This happens all the time in couple therapy because sometimes it is easier to initially open up pockets of grief with someone you are not married to. But I  hear you saying you’ve wanted to connect with Craig around your sense there must be pain there [she nods, tearing up] . . . and I can’t help but wonder if that might be from your concern for him and also from some of what you know from your own experience of loss.

This intervention resulted in a softening in both, and the de-triangulating maneuver allowed the therapist to continue to deepen his alliance with both partners while establishing a fair and safe attachment with the couple system. The connection with Craig around emotional vulnerability countered his avoidant attachment tendencies, and seeing this activated shame-prone, ambivalent attachment tendencies in Jovelyn. While shifting momentarily to dialogue with Jovelyn might seem to distract from grief work with Craig, it was actually helpful in this session because it offered Craig a break after several minutes of rather intense processing of painful emotions and prevented his feeling over-exposed at this early phase. The therapist also took a risk in naming a perceived attachment desire in Jovelyn, which proved accurate and facilitated connection with her in feelings of loss and vulnerability.

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Co-Constructing a Developmental Crucible Numerous clinical theorists and spiritual writers have used the crucible as a metaphor for the process of transformation (Worthington & Sandage, 2016), and in the couple therapy field Schnarch (2009) has made the most elaborate use of the crucible metaphor. A crucible is a furnace or container that holds the intense, fiery process of transforming base metals into precious ones. Schnarch speaks to the deep, anxiety-provoking dilemmas and conflicts that emerge in couples who enter a crucible process that requires them to either grow developmentally in DoS or end their relationship. In our relational spirituality model, crucible processes can also include the intensification of existential and RS longings and concerns that hold ultimate significance for one or both partners, including questions like “Can I ever really be forgiven and loved?,” “Can I remain true to myself and also know intimacy with someone else?,” “Do people just want to use me for their own ends or is it possible to really trust and rely on someone in life?,” and “Has God (or some other description of the sacred) destined me to a fate of solitary punishment and suffering or is there some way we might actually find healing and happiness together?” Co-constructing a developmental crucible means drawing on these kinds of latent questions and concerns that clients reveal in telling their stories and weaving them into a frame for developmental growth. In this case, Jovelyn eventually described “always feeling like a disappointment,” which motivated her efforts to please others. She experienced her mother as inconsistent and longed for her father’s approval, but always felt he held something back. She risked conflict with him shortly before his death, which felt like traumatic confirmation that she was the problem. Craig uncovered his own relational strategy of “trusting no one” and “impressing people to get what you need.” The therapy dialogue co-constructed the understanding that both had been engaging in lifelong relational “sales strategies” (pleasing, impressing) in their quests for connection, but both had ended up feeling alone spiritually and in marriage. Once their respective stories were tied to this formulation of the problem, the therapist was able to frame the crucible question—did they want to give up their sales strategies and work at developing capacities for authentic connection as equal partners? Craig was able to admit he had never learned to collaborate with others as equals and was typically nervous when others did not idealize him or defer to his superior insight. He still had concerns about Jovelyn’s embrace of Buddhism, but he now had more differentiated awareness of multiple dynamics at play. He previously thought he was just defending religious truth, but he came to realize part of his anxiety was the loss of influence (or power) he felt as she explored a spirituality that was unfamiliar to him and outside his control. With a developing therapeutic alliance, the therapist was able to invite Craig to self-confrontation through a

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question about what it might take for him to “trust God with Jovelyn’s spiritual search rather than trying to control it himself.” This helped Craig grapple with and eventually deepen his own relational spirituality. Jovelyn realized that she did not know how to relate to people she was not trying to please and that she was anxious about losing her newfound sense of self-identity and emotional freedom if she came back into relationship with Craig. As soon as she started to empathize with his pain and anxieties, she started to feel guilty for her RS explorations. Fortunately, she was able to see this was part of the old pattern of self-diminishment that had proved unhelpful. Processing Disappointment and Grief The conversations in therapy about the RS journeys for Jovelyn and Craig led into the sensitive terrain of disappointment and grief. Each had experienced major losses that were either repressed (Craig) or spiritually complicated (Jovelyn). They had never had anyone help them process these losses in each other’s presence and to supportively surface the anxieties and relational messages they had internalized. This further helped frame some depth of context around their spiritual journeys and relational spirituality differences. The therapist also explored the similarities and differences within their painful church experience when Craig was in ministry. They shared some disappointment about the church leaders and overall dynamics, although some defensiveness initially flared up in Craig over this topic. Noting the shift in affect, the therapist helped Craig get in touch with (1) guilt he felt about the impact of his church role and the unfair expectations on Jovelyn and (2) rage he felt at the senior pastor who was so insensitive to their losses with the miscarriages. The rage was partly reflective of feelings about his own father and the fragmentation he would start to feel when his relational strategy of impressing people inevitably failed to earn him the acceptance he desired. Over several months, effectively processing these difficult experiences together in therapy helped this couple develop the distress tolerance to even talk about disappointments they had with each other and themselves during these difficult periods. The therapist helped them work on consciously differentiating the healthy humility of learning, apologizing, and grieving from the cycles of blaming, shaming, and avoiding. Cultivating and Extending Differentiation The therapeutic process was not linear for this couple, but over three years they developed a more differentiated and securely attached relationship through individual and couples therapies. Initial gains came from help (1) reducing their negative interaction patterns and (2) processing their unique and shared losses together in ways that cultivated bonding amid their

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differences. Work on their cultural differences and intercultural competence represented another domain of growth in DoS, and this served to broaden their awareness and understanding of their RS conflicts. To put it differently, they used their mutual attachment with the therapist to practice and develop DoS in some other areas rather than focusing all their emotional energy on RS differences, which seemed existentially overwhelming to this couple. In the process, RS differences became somewhat less anxiety-provoking, in part because they had developed more capacity to connect, collaborate, and handle differences. Craig came to the conclusion he needed to focus more on his own spiritual development, and his growing humility allowed him to respect Jovelyn in her choices and RS practices. It is important to note this could have turned out differently, and if he had been unable to respect her freedom and RS choices it could have intensified a crucible for both about whether capitulate or divorce. In our relational spirituality model, initial gains in differentiation need to be extended into other areas to achieve more complete second-order transformation of a couple system. During years two and three of couple therapy, Jovelyn and Craig focused work on improving their sexual relationship and collaboration as an interracial couple in the white supremacist context of the United States. They moved from overwhelming conflict and the question— “Can we stay together?”—to the questions of intimacy, enjoyment, and solidarity in their relationship (i.e., “How can our relationship flourish?”). This required applying their new and more differentiated patterns of relating to these other areas of their relationship, and this also meant new explorations for each of them in ways of integrating their relational spiritualities with sexuality and social justice. Eventually, this also required developing new interculturally sensitive support networks beyond therapy to help sustain them as a more differentiated couple. Conclusion Spirituality and religious identity have been overlooked within couples work in the traditional field of couples counseling. This chapter has reviewed a relational spirituality model and used a case to illustrate how a couples’ therapist might operationalize the model in couples work. Understanding and working with couples’ spiritual and religious identities is often key to treatment success, especially in couples that consider their religion and/or spiritual beliefs to be important parts of their identity, or in couples where their religious and spiritual belief systems are in conflict with one another. This chapter has also provided a list of some of the common problems RS couples present with in couple therapy. We also discussed specific strategies to help counselors evaluate the religious/spiritual identities of the couples with whom they work as well as given treatment recommendations for work with RS couples.

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References American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Association. Bennett, M. J. (2004). Becoming interculturally competent. In J. Wurzel (Ed.), Toward multiculturalism: A reader in multicultural education (2nd ed., pp. 62–77). Newton, MA: Intercultural Resource Corporation. Brelsford, G. (2011). Divine alliances to handle family conflict: Theistic mediation and triangulation in father-child relationships. Psychology of Religion and Spirituality, 3(4), 285–297. Brennan, K. A., Clark, C. L., & Shaver, P. R. (1998). Self-report measurement of adult attachment: An integrative overview. In J. A. Simpson  & W. S. Rholes (Eds.), Attachment theory and close relationships (pp.  46–76). New York, NY: Guilford Press. Ferguson, J. K., Willemsen, E. W., & Castañeto, M. L. V. (2009). Centering prayer as a healing response to everyday stress: A psychological and spiritual process. Pastoral Psychology, 59, 305–329. Fincham, F., Beach, S., Kaslow, N. J., Mahoney, A., & Cano, A. (2014). I Say a Little Prayer for you: Praying for partner increases commitment in romantic relationships. Journal of Family Psychology, 28(5), 587–593. Mikulincer, M., & Shaver, P. R. (2016). Attachment in adulthood: Structure, dynamics, and change. New York, NY: Guilford Press. Pargament, K. I., Magyar, G. M., Benore, E., & Mahoney, A. (2005). Sacrilege: A study of sacred loss and desecration and their implications for health and well-being in a community sample. Journal for the Scientific Study of Religion, 44(1), 59–78. Pew Research Center. (2015, May). America’s changing religious landscape. Retrieved from America’s Changing Religious Landscape website www.pewforum. org/2015/05/12/americas-changing-religious-landscape/ Rowatt, W. C., & Kirkpatrick, L. A. (2002). Two dimensions of attachment to God and their relation to affect, religiosity, and personality constructs. Journal for the Scientific Study of Religion, 41(4), 637–651. doi:10.1111/1468-5906.00143 Sandage, S. J., Jankowski, P. J., Crabtree, S., & Schweer, M. (2015). Attachment, spirituality pathology, and God images: Mediator and moderator effects. Mental Health, Religion, and Culture, 18, 795–808. Schnarch, D. (2009). Passionate marriage. New York, NY: W. W. Norton & Company. Sloan, D., & Van Dierendonck, D. (2016). Item selection and validation of a brief, 20-item version of the Differentiation of Self Inventory—Revised. Personality and Individual Differences, 97, 146–150. Stafford, L. (2016). Marital sanctity, relationship maintenance, and marital quality. Journal of Family Issues, 37(1), 119–131. Tummala-Narra, P. (2016). A psychoanalytic theory and cultural competence in psychotherapy. Washington, DC: American Psychological Association. Ungureanu, I., & Sandberg, J. G. (2010). “Broken together”: Spirituality and religion as coping strategies for couples dealing with the death of a child: A  literature review with clinical implications. Contemporary Family Therapy: An International Journal, 32(3), 302–319. doi:https://doi.org/10.1007/s10591-010-9120-8 Walsh, F. (2013). Religion and spirituality: A  family systems perspective in clinical practice. In K. I. Pargament (Ed.), APA handbook of psychology, religion, and spirituality: Vol. 2 An applied psychology of religion and spirituality (pp. 189–205). Washington, DC: American Psychological Association.

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Winawer, H.,  & Wetzel, N. A. (2005). German families. In M. McGoldrick, J. Giordano, & N. Garcia-Preto (Eds.), Ethnicity & family therapy (3rd ed., pp. 555– 572). New York, NY: Guilford Press. Worthington, E. L., Jr., & Sandage, S. J. (2016). Forgiveness and spirituality: A relational approach. Washington, DC: American Psychological Association.

PART IV

Treating Disordered Couples: Retrospective and Prospective

19 THE DISORDERED COUPLE Past, Present, and Future Len Sperry and Katherine Helm

P

How Couples Present for Couple Therapy: In the Past and In the Present

revious chapters have noted several changes in couple therapy in the recent past. One of these changes has been in the ways in which couple present for conjoint therapy. As we noted earlier in this book, a relatively common presentation from the 1940s through the mid-1980s was for couples to present with relationship issues for which therapy often involved understanding, information, or help with communicating more effectively. Couples seldom presented with DSM individual diagnoses or DSM relational disorders. If one partner experienced a DSM disorder, it was likely treated primarily in individual therapy and may have included medication. Beginning in the late 1980s and early 1990s, we noticed that more couples were presenting with individual disorders and/or relational disorders. It is no coincidence that DSM-IV, which appeared in 1994 added the relational disorders. The reason for this inclusion is that these disorders were increasingly common and prevalent. The first edition of this book appeared in 1998 and reflected this change. It was the first book on disorders in couples. In Chapter 3, we briefly described four broad categories for understanding and classifying couples in terms of individual disorders and relationship disorders (Reiss, 1996). While helpful, these categories do not, in our estimation, include all of the ways couples present for treatment today. Accordingly, as we conclude this book, the following 2 × 2 table (Table 19.1) is offered, which provides a context for understanding the way in which couples present for couple therapy today. Five types of couples are noted in Table  19.1, which characterizes the ways in which couples present for conjoint treatment today. While Type 1

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characterizes the most common way couples presented for therapy decades ago, couples today are just as likely, or more likely, to present with Types 2–5. Trainees find this graphic clinically useful in understanding and conceptualizing couples who present for conjoint therapy today. Table 19.1  Types of Couple Presentations: Relational vs. Individual Diagnoses INDIVIDUAL DIAGNOSIS (-)

(+)

(-)

Type 1

Type 4

(+)

Type 2

Types 3 & 5

RELATIONAL DIAGNOSIS

Type 1. No Relational Disorder or Individual Disorder These couples do not meet criteria for a DSM-5 individual disorder or a DSM-5 relational disorder. Typically, they tend to function reasonably well but may present for couple therapy for a specific relational issue or concern. Type 2. Relationship Disorders Only These couples experience relationship distress that is characteristic of a DSM-5 relational disorder. Type 3. Relationship Disorders and Individual Disorders These couples are identified by a DSM-5 relational disorder as well as a DSM-5 individual disorder in one of the partners. Although not as common, both partners may present with diagnosable DSM-5 individual disorders. Type 4. Individual Disorders Only These couples are identified with a DSM-5 individual disorder that has little or no relational impact. Type 5. Individual Disorders With Relational Impact These couples are identified with a DSM-5 individual disorder in one partner for which there is considerable relational impact. However, it does not meet criteria for a relational disorder.

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In the second edition of The Disordered Couple, we have reviewed the most current literature on disordered couples. Each chapter author provided current treatment and assessment recommendations and then utilized a case example to illustrate how clinicians might operationalize the recommendations provided in each chapter. Special attention was given to multicultural issues, culturally sensitive practice, and an expansion of the depth and breadth of the types of couples included in this edition of the book. Additionally, we explored how these issues can impact the presentation of psychopathology and its influence on the couple relationship and in couple counseling. Table 19.1 provides an important historical context that practitioners can use to understand the development of couple treatment as a modality and its current trajectory. Couples work over the last 30 years been transformed by the following influences: a shift from a communication foci to couples models focused on emotional connectivity and attachment (e.g., emotionfocused couple therapy), shared meaning and values (e.g., John Gottman’s work), and cognitive–behavior influences on a couple’s relationship; the inclusion of diverse couples (e.g., racially/ethnically, same-sex, Muslim, interaction and other types of couples); and other powerful influences (e.g., the Internet, social media). More empirically based research on what works in improving couples’ relationships has made important contributions to the field. Additionally, couples practitioners are increasingly relying on continuous assessment throughout the therapeutic process, which can be highly beneficial for making changes within the ongoing treatment process, as opposed to waiting until counseling concludes. The course of couple therapy is rapidly changing in some exciting ways. For many families, couple therapy is quickly becoming the treatment of choice over individual, family, and group counseling methods, and more couple therapists are incorporating a diagnostic foci when one member of the couple has a psychological disorder. This in itself demonstrates the flexibility of couples work as a treatment modality. However, because there continues to be limited research on couples in which one member of the couple experiences a psychological disorder, this will be an important continued direction for research. Additionally, given the limited research on same-sex couples and the paucity of research on transgender couples, this is another emergent area. It is our hope that this text augments knowledge of couples practitioners on how to effectively address psychopathology as it occurs within the couple relationship. When one (or both) members of a couple experience a psychological disorder, it significantly impacts the couple relationship and couple counseling. Without acknowledging and, in some cases, addressing the disorder, couples treatment is not nearly as effective as it might be. Effective couple counselors understand that they cannot separate one member’s struggle with depression (or other disorders) out of their relationship, as it

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influences the couple as a whole. This book is intended to assist practitioners and counselors-in-training in this aim. Reference Reiss, D. (1996). Foreword. In F. Kaslow (Ed.), Handbook of relational diagnosis and dysfunctional family patterns (pp. ix–xv). New York, NY: John Wiley & Sons.

INDEX

abstinence, supporting 233 – 234 accommodation and online relationships 30 acculturation and cultural dynamics 180 – 181 addiction 222; see also sexual addiction; substance use/abuse ADHD see Attention-Deficit/ Hyperactivity Disorder Adjustment Disorders 291–292, 299 Adult ADHD Self-Report Rating Scale 262 affective cluster of BPD 140 African American couples 17 – 18 aggression: BPD and 138; PTSD and 120; see also domestic violence agreement on presenting problems 12 – 13 Alcohol Use Disorder 229 – 230, 233 alliance in couple therapy 11 – 12, 182 – 183, 189 ambiguity and online relationships 30 American Psychological Association, Resolution on Family Caregivers 291 anonymity and online relationships 29 – 30 Anorexia Nervosa (AN) 193, 197, 200 – 201 anxiety: assessment of 110 – 111, 114 – 115; attachment styles and 104 – 107; case conceptualizations

for 115 – 116; case example 112 – 117; couples and 107 – 108; cultural dynamics in 112; purpose of 104; situation, circumstance, and 108 – 109; treatment for 116 – 117 Anxiety Disorder Interview Schedule 111 anxious/preoccupied attachment 198 Asian/Asian American couples 18 – 19 assessment: of ADHD 261 – 262; of anxiety 110 – 111, 114 – 115; of Borderline Personality Disorder 139 – 140, 148; case examples 74; of cultural dynamics 43 – 44; of depressive disorders 69 – 70; of domestic violence 277, 282 – 283; of explanatory model 44 – 45; of histrionic-obsessive couples 178, 185 – 186; of Narcissistic Personality Disorder 157 – 159, 163; of Paraphilic Disorder 210 – 212, 215 – 216; of psychosis 88 – 94, 96, 98 – 99; of relational dynamics 43, 78; of relational history 42 – 43; of religious and spiritual problems 310 – 312; of sexual addiction 242 – 243; of social media and technology issues 33 – 34, 38 – 39; of stage of life issues 293 – 295, 297; standardized inventories for 54 – 55; of strengths and resources 44; of substance use 224 – 225, 228 – 229; of trauma 126 – 127

330 Index

attachment styles: anxiety and 104 – 107; childhood trauma and 121; Eating Disorders and 195 – 196, 198; religious and spiritual problems and 310 – 311, 312 – 313, 315 – 316 Attachment to God scale 311 attack/attack pattern 47 Attention-Deficit/Hyperactivity Disorder (ADHD): in adults 255 – 256; assessment of 261 – 262; case conceptualizations for 256; case example 267 – 268; cognitive behavioral therapy groups for 265; communication issues and 260 – 261; cultural dynamics in 263 – 264; diagnosis of 255; Imago Relationship Therapy for 265 – 266; Orlov’s model for 266 – 267; overview 254 – 255, 268 – 269; social skills techniques for 264 – 265; treatment for 256 – 260 avoidant/dismissive attachment 198, 312 – 313 avoiding type of psychosis 87 – 88 balance, restoring to relationships 48, 59, 91, 183, 189 – 191 BD see Bipolar Disorder Beck Anxiety Inventory 111 Behavioral Couple Therapy (BCT) 13 – 14, 226 – 227, 232 – 235 bereavement, spousal 291, 294 – 295; see also stage of life issues Binge Eating Disorder (BED) 195, 197 – 198 biological domain of assessment 210 Biosocial Transactional Model 137 Bipolar Disorder (BD): assessment of 69 – 70; case example 72 – 78; diagnosis of 66; psychosis in 89, 95 – 97; stressors and functioning with 66 – 69; treatment for 70 – 72, 74 – 78 Borderline Personality Disorder (BPD): assessment of 139 – 140, 148; case conceptualizations for 140 – 142, 148 – 149; case example 147 – 150; cultural dynamics in 142 – 143, 149; diagnosis of 139; domestic violence and 276; etiology of 137 – 138; overview 136 – 137; relational

dynamics of 138 – 139; treatment for 136, 143 – 147, 149 – 150 boundaries between work and home life, as blurred 30 – 31 Bulimia Nervosa (BN) 193, 194, 197 case conceptualizations: ADHD 256; anxiety 115 – 116; Borderline Personality Disorder 140 – 142, 148 – 149; case example 58 – 59; centrality of patterns and 56 – 57; domestic violence 277 – 278, 282 – 284; Eating Disorders 198; histrionicobsessive couples 178 – 180, 186 – 188; individual 57 – 58; Narcissistic Personality Disorder 157, 163 – 164; overview 55 – 56; Paraphilic Disorder 212, 216 – 217; psychosis 91 – 94, 96, 99; religious and spiritual problems 312 – 313; sexual addiction 243 – 245, 250 – 251; social media and technology issues 34 – 35, 38; stage of life issues 292 – 293, 299 – 302; substance use/ abuse 228 – 229; trauma 127 – 128, 132 case examples: anxiety 112 – 117; assessment 74; Bipolar Disorder 72 – 78; Borderline Personality Disorder 147 – 150; case conceptualizations 58 – 59; diagnosis 58 – 59; domestic violence 281 – 286; Eating Disorders 202 – 204; histrionicobsessive couples 184 – 191; Internet infidelity 37 – 40; Narcissistic Personality Disorder 161 – 167; Paraphilic Disorder 213 – 220; PostTraumatic Stress Disorder 131 – 134; psychotic couples 95 – 101; religious and spiritual problems 307 – 319; sexual addiction 248 – 251; stage of life issues 295 – 302; substance use/abuse 228 – 235; treatment plan 58 – 59 CBCT (cognitive-behavioral couple therapy): for ADHD 265; for Eating Disorders 200 – 201 character disorders 82; see also personality disorders childhood trauma 121, 277 children: of NPD parents 155 – 157; use of, in emotional abuse 274

Index  331

circumstance and anxiety 108 – 109 Clinician Administered PTSD Scale for DSM-5 132 coaddicts and sexual addiction 244 – 245, 246, 247 – 248 coercion and domestic violence 272 – 273 cognitive-behavioral couple therapy (CBCT): for ADHD 265; for Eating Disorders 200 – 201 Cognitive Neuroscience Theory of Psychosis 85 – 87 combat trauma 120 – 121 communication work: for ADHD 260 – 261, 264 – 265; myth about 3 – 4 compulsive sexual behavior see sexual addiction Conner Adult ADHD Rating Scales 262 constructive engagement 47 Contextual Reinforcement Model 154 Continuing Bonds Scales 295 controlling partners and psychosis 90, 91 countertransference: ADHD and 259 – 260; personality disorders and 53 couple case conceptualization 34, 42, 45, 58 – 60, 115, 127, 132, 141, 149, 157, 179, 187, 198, 251, 256, 278, 283, 292, 301 Couples Satisfaction Index 294 couple therapy: alliance in 11 – 12, 182 – 183, 189; course of 327 – 328; individual therapy vs. 4 – 5, 10 – 11; myths about 2 – 5; presenting for, changes in 325 – 327; relational spirituality model of 315 – 319; remarital 23 – 24; training in 4; trends in field of 1; types of 13 – 14; see also cognitive-behavioral couple therapy; emotion focused couple therapy (EFCT)/emotion focused therapy (EFT); rebalancing couple relationships cross-dressing 209 crucible, developmental, co-constructing 317 – 318 cultural dynamics/issues: in ADHD 263 – 264; in anxiety 112; in Borderline Personality Disorder

142 – 143, 149; in domestic violence 278 – 279, 284; in histrionic-obsessive couples 180 – 181, 188; in Narcissistic Personality Disorder 159; overview 15 – 22, 43 – 44; in Paraphilic Disorder 212, 217; in psychosis 94 – 95, 98; in religion and spirituality 313 – 315; in sexual addiction 245 – 246, 251; in social media and technology use 35; in stage of life issues 295, 301 – 302; in substance use 227, 231; in trauma 128 – 129, 133 cybersex engagement 30, 32 – 33 cycle of violence 275 – 276 DBT (Dialectical Behavior Therapy) 136, 143 – 147, 149 – 150 deindividuation and online relationships 29 Delusional Disorder 92, 101 demand/submit pattern 46 demand/withdraw pattern 46, 51 – 52 dependent partners and psychosis 90 – 91 depression see Bipolar Disorder; Major Depressive Disorder developmental issues see religion and spirituality; stage of life issues Developmental Model of Intercultural Sensitivity 313 – 314 diagnosis: of ADHD 255; of anxiety disorders 109 – 110, 114 – 115; case example 58 – 59; of depressive disorders 66; of domestic violence 276 – 277; of histrionic-obsessive couples 177 – 178; of Paraphilic Disorder 208 – 210, 214 – 215; of personality disorders 52 – 54; of relationship disorders 49 – 50, 54, 291 – 292; of religious or spiritual problems 307; of sexual addiction 242, 250; of stage of life issues 291 – 292, 298 – 299; of substance abuse 224 – 225, 229 – 230; of symptom disorders 51 – 52; systemic perspective and 48 – 49; of trauma 125 – 126; value of 50 Diagnostic and Statistical Manual (DSM-5): Adjustment Disorders 202,

332 Index

299; Alcohol Use Disorder 229 – 230; Attention-Deficit/Hyperactivity Disorder 255; Bipolar Disorder 66; Borderline Personality Disorder and 139; categorical approach of 109; Feeding and Eating Disorders 196 – 198; “Glossary of Cultural Concepts of Distress” 94; Major Depressive Disorder 66; Narcissistic Personality Disorder 158, 163; on personality disorders 53 – 54; of psychosis 88, 98; on relationship disorders 49 – 50, 325; Relationship Distress with Spouse or Intimate Partner 291, 299; systemic thinking and 4; value of 50; V-code for relational distress 54; V-code for religious or spiritual problems 307 diagnostic inventories, standardized 54 – 55 Dialectical Behavior Therapy (DBT) 136, 143 – 147, 149 – 150 differentiation of self (DoS): cultivating and extending 318 – 319; relational spirituality and 311 disappointment, processing 318 disclosure: of domestic violence 272; of sexual addiction 247 – 248 dismissive-avoidant attachment style 115 – 116 domestic violence (DV): assessment of 277, 282 – 283; case conceptualizations for 277 – 278, 282 – 284; case example 281 – 286; cultural dynamics in 278 – 279, 284; cycle of 275 – 276; diagnosis of 276 – 277; economic abuse 274; emotional abuse 273 – 274; overview 271 – 272, 286; physical abuse 272 – 273; sexual abuse 273; treatment for 279 – 281, 284 – 286 Dyadic Adjustment Scale 111, 178

electronic devices see social media and technology emotional abuse 273 – 274 emotional contagion 108 emotional expression 68 emotion focused couple therapy (EFCT)/emotion focused therapy (EFT): for anxiety 110; for Eating Disorders 195 – 196, 201 – 202, 203 – 204; overview 13, 14; for PTSD 129 – 131, 133 – 134 empathy, bilateral 78 environmental domain of assessment 212 executive functions and ADHD 260, 262 exhibitionism 208 – 209 exhibitionist subtype of NPD 158 expectations: gender-based 295, 297 – 298, 299 – 300, 301 – 302; for relationships 3; for treatment 44 Experiences in Close Relationships scale 310 explanatory model 44 – 45, 180 explosion phase of domestic violence 275 – 276

Eating Disorders (EDs): attachment patterns in 195 – 196, 198; case conceptualizations for 198; case example 202 – 204; diagnosis of 196 – 198; effects of 194 – 195; overview 193 – 194; treatment for 196, 198 – 202 Ecological Elements Questionnaire 34 economic abuse 274

gender: ADHD and 263; domestic violence and 271, 278 – 279; expectations based on 295, 297 – 298, 299 – 300, 301 – 302; histrionicobsessive couples and 170 – 171, 181; infidelity and 33, 35; sexual addiction and 246; social media and technology use and 35

family disease model of substance abuse 226 family ecology perspective on technology 29 family-of-origin issues 15, 42 – 43 family systems perspective on substance abuse 226 fearful avoidant attachment style 106 fetishes 209 Finkel, Eli, The All or Nothing Marriage 3 flexibility in treatment process 235 fragile subtype of NPD 157 frotteuristic disorder 208 Functional Analytic Psychotherapy 160

Index  333

Generalized Anxiety Disorder: attachment and 106 – 107; case example 112 – 117; symptoms of 109 genograms 34, 43, 261 getting type of psychosis 87 – 88 grandiose subtype of NPD 157 – 158 grief, processing 318 Grief Experience Inventory 295 heterosexism, systematic 231 histrionic-obsessive couples: assessment of 178, 185 – 186; case conceptualizations for 178 – 180, 186 – 188; case example 184 – 191; conflicts in 174 – 175; cultural dynamics in 180 – 181, 188; diagnosis of 177 – 178; gender and 170 – 171, 181; mate selection for 172 – 174; treatment for 172 – 174 Histrionic Personality Disorder 177 hoarding disorder 110 homosexual couples see same-sex couples honeymoon phase of domestic violence 276 hope, fostering 123 – 124 hyperfocus 260 hypersexuality see sexual addiction identity cluster of BPD 140 Imago Relationship Therapy 265 – 266 impulsive cluster of BPD 140 inattention see Attention-Deficit/ Hyperactivity Disorder individual therapy vs. couple therapy 4 – 5, 10 – 11 infantilism 209, 213 – 214 infidelity see Internet infidelity Integrative Behavioral Couple Therapy 14 interaction-constructionist perspective on technology 29 intercultural couples 19 – 20; see also cultural dynamics/issues interfaith couples 305 – 306; see also religion and spirituality intergenerational domain of assessment 211 Internet infidelity: attitudes toward 32 – 33; case example 37 – 40; gender and 35;

overview 31; rates of 28; treatment for 36 – 37; warning signs of 33 Internet sexual addiction 240 – 241 interpersonal trauma 121 – 122 interracial couples 19 – 20; see also cultural dynamics/issues Intimate Partner Violence see domestic violence Inventory of Traumatic Grief 295 isolation and domestic violence 274 jealousy and technology 31 Kansas Marital Satisfaction Scale 111 kinky sex 207 – 208, 220; see also Paraphilic Disorder Latino/a couples 18 lesbians, alcohol use among 231; see also same-sex couples Liebowitz Social Anxiety Scale 111 Major Depressive Disorder: assessment of 69 – 70; diagnosis of 66; domestic violence and 276; psychosis in 89, 93; stressors and functioning with 66 – 69; treatment of 70 – 72, 74 – 78 male privilege and domestic abuse 274 Marital Assessment Test 110 – 111 Marital Satisfaction Inventory-Revised 178 marriage types 3 masochism, sexual 209 mate selection for histrionic-obsessive couples 172 – 174 meaning of symptoms of psychosis 100 Millon Clinical Multiaxial Inventory (MCMI-IV) 55, 88 – 89, 178 mood disorders, psychosis in 89; see also anxiety; Bipolar Disorder; Major Depressive Disorder multicultural counseling 15 – 17 Multitheoretical Model 29 – 30 Muslim couples 20 – 21 Narcissistic Personality Disorder (NPD): assessment of 157 – 159, 163; Borderline Personality Disorder and 142; case conceptualizations for 157, 163 – 164; case example 161 – 167; children of couples with

334 Index

155 – 157; cultural dynamics in 159; diagnosis of 153, 163; functioning levels of 158 – 159; overview 153 – 154; relational dynamics in 154 – 155; treatment for 154 – 155, 164 – 167 Narcissistic Personality Inventory 158 narcissistic rage 161 neuroscience theory of psychosis 85 – 87 neurosis 82 object relations and NPD 161 Obsessive-Compulsive Disorder (OCD) 107, 108, 110, 177 – 178 obsessive-compulsive partners 170, 171 online infidelity see Internet infidelity online sex addiction 240 – 241 Orlov model for treatment for ADHD 266 – 267 Panic Disorder 109 – 110 paraphilia and sexual addiction 244 Paraphilic Disorder: assessment of 210 – 212, 215 – 216; case conceptualizations for 212, 216 – 217; case example 213 – 220; cultural dynamics in 212, 217; diagnosis of 208 – 210, 214 – 215; overview 207 – 208; treatment for 212 – 213, 218 – 220 parent-child dynamic and ADHD 258 – 259 patterns see relational interaction patterns pedophilia 209 Perceived Stress Scale 294 Perceived Support Scale 294 personality disorders: sexual addiction and 244; treatment for 52 – 54, 176 – 177; see also Borderline Personality Disorder; histrionicobsessive couples; Narcissistic Personality Disorder pharmacotherapy: for ADHD 268; for Bipolar Depression 70, 77; for Narcissistic Personality Disorder 160; for Schizophrenia 99 physical abuse 272 – 273 pornography, compulsive use of 240 – 241, 248 – 251 postpartum depression 66

Post-Traumatic Stress Disorder (PTSD): case conceptualizations for 127 – 128, 132; case example 131 – 134; combatrelated 120 – 121; diagnosis of 125 – 126; domestic violence and 276; in non-sexually addicted partners 244; relational distress and 122 – 123; symptoms of 119, 120; treatment for 129 – 131, 133 – 134 preoccupied attachment style 106 presenting problems: agreement on 12 – 13; explanatory model and 44 – 45; over time 325 – 327 Psychodynamic Diagnostic Manual 158 psychoeducation: for ADHD 266; for Bipolar Depression 70, 71, 76; for domestic violence 280; for Eating Disorders 200 psychological domain of assessment 210 – 211 psychological theory of psychosis 82 – 84 psychopathology: attachment and 106 – 107; individual vs. couple therapy and 4 – 5, 10 – 11; relational distress and 8 – 11, 65 psychosis: assessment of 88 – 94, 96, 98 – 99; case conceptualizations for 96; case examples 95 – 101; as co-created and used 87 – 88; cultural dynamics in 94 – 95, 98; diagnosis of 88, 98; experience of 80 – 81; neuroscience theory of 85 – 87; psychological theory of 82 – 84; symptoms of 82; treatment for 97, 99 – 101 PTSD see Post-Traumatic Stress Disorder purpose of symptoms of psychosis 100 – 101 race see cultural dynamics/issues Rational Emotive Behavioral Treatment (REBT) 163, 164 – 166 reactive demand/withdraw pattern 47 rebalancing couple relationships 48, 59, 91, 183, 189 – 191 reimbursement issues 48 – 49 relational distress: diagnosis of 291 – 292; DSM-5 V-code for 54; over time 325 – 328; psychopathology and 8 – 11, 65; trauma and 122 – 123

Index  335

relational dynamics/interaction patterns: assessment of 43; of Borderline Personality Disorder 138 – 139; in case conceptualizations 56 – 57; of Eating Disorders 195 – 196; modifying 183 – 184; of Narcissistic Personality Disorder 154 – 155; of Paraphilic Disorder 211; of psychosis 90 – 91, 92 – 94; of sexual addiction 241 – 242, 245; symptom disorders and 51 – 52; types of 45 – 48; see also case conceptualizations relational history 42 – 43 relational spirituality model of couple therapy 315 – 319 relationship disorders 49 – 50; see also relational distress; relational dynamics/interaction patterns relaxation training 99 – 100 religion and spirituality: assessment of 310 – 312; attachment patterns and 310 – 311, 312 – 313, 315 – 316; case conceptualizations for 312 – 313; case example 307 – 319; cultural dynamics in 313 – 315; overview 305 – 307, 319; treatment for problems of 315 – 319; V-code for 307 remarital couple therapy 23 – 24 reproductive coercion 273 Resolution on Family Caregivers (APA) 291 response to symptoms of psychosis 100 – 101 sadism, sexual 209 safety, establishing, in treatment for domestic violence 279 – 280 same-sex couples: ADHD and 263; alcohol use among 231; domestic violence and 279, 281 – 286; treatment for 21 – 22 sandwich caregiving 290 – 291, 294, 295 – 302; see also stage of life issues Schizophrenia case example 97 – 101 secure attachment style 105 – 106 self-report measures: for anxiety 111; for NPD 158 semi-structured interviews for NPD 158 sexual abuse 273

sexual addiction: assessment of 242 – 243; case conceptualizations for 243 – 245, 250 – 251; case example 248 – 251; cultural dynamics in 245 – 246, 251; diagnosis of 242, 250; Internet-based 240 – 241; overview 238 – 240, 252; relational dynamics and 241 – 242, 245; treatment for 246 – 248, 251 SFT (solution focused therapy) for Eating Disorders 201 – 202, 203 – 204 situation and anxiety 108 – 109 social anxiety disorder 107, 109 social deficits in ADHD 257 – 258 social media and technology: assessment of use of 33 – 34, 38 – 39; case conceptualizations for 34 – 35, 38; case example 37 – 40; cultural dynamics in 35; impact of 28 – 32; see also Internet infidelity Social Phobia Inventory 111 socioeconomic (SES) issues 22 – 23 solution focused therapy (SFT) for Eating Disorders 201 – 202, 203 – 204 splitting and NPD 160 – 161 spousal bereavement 291, 294 – 295; see also stage of life issues stage of life issues: assessment of 293 – 295, 297; case conceptualizations for 292 – 293, 299 – 302; cultural dynamics in 295, 301 – 302; diagnosis of 291 – 292, 298 – 299; overview 289 – 291; treatment for 302 – 303 strengths and resources, assessment of 44 Stress-Diathesis Model of psychosis 83 Structural Analysis of Social Behavior 141 structural-functional perspective on technology 29 substance use/abuse: assessment of 224 – 225, 228 – 229; case example 228 – 235; cultural dynamics in 227, 231; diagnosis of 224 – 225, 229 – 230; domestic violence and 276; family dysfunction and 223; impact of 222; influences on 223, 224; overview 235 – 236; PTSD and 120 – 121; sexual addiction and 244; statistics on 222; treatment for 223 – 224, 225 – 226

336 Index

survivors of domestic violence, disclosure by 272 symptom disorders 51 – 52 systemic dynamics and patterns, assessment of 45 systemic perspective and diagnosis 48 – 49 systemic thinking 4 Technological Genogram 34 technology see social media and technology Technology and Intimate Relationship Assessment 34 tension-building phase of domestic violence 275 therapeutic alliance in couple therapy 11 – 12, 182 – 183, 189 thought disorders 88, 89, 92, 93 Traditional Behavioral Couple Therapy (TBCT) 14 training in couple therapy 4 trauma: assessment of 126 – 127; case conceptualizations for

127 – 128, 132; in childhood 121, 277; cultural dynamics in 128 – 129, 133; diagnosis of 125 – 126; relational distress and 122 – 123; symptoms of 119 – 120; treatment for 123 – 125; types of 120 – 122; see also Post-Traumatic Stress Disorder treatment plan: case example 58 – 59; flexibility in 235 Uniting Couples in treatment of Anorexia Nervosa (UCAN) 200 – 201, 204 voyeurism 208 withdraw/withdraw pattern 46 worldviews: in case conceptualizations 179 – 180; in personality disorders 54; in PTSD 128 Yale-Brown Obsessive-Compulsive Scale 111