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Outline of Carl Whitaker’s The Roots of Psychotherapy

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[First published on Nathen’s Miraculous Escape, January 9, 2011.]

I started reading The Roots of Psychotherapy last summer, on the advice of John Miller, one of the heads of my Couples and Family Therapy program. He hadn’t actually read it, but had had it so highly recommended to him by a respected colleague that John wished he had time to read it. It was not an easy read, but interesting to see what looked like Whitaker’s explanation of his transition from psychiatry and psychoanalysis to the experiential family therapy of his later career.

This outline is incredibly sloppy, thanks mostly to Open Office’s awful outlining, but the guts of the book as I understand it are here.

A. Foundation

1. Science as a Creative Method

a) Role of the Unconscious (Intuition): Operationalization is tricky in science in general, and in research into psychotherapy in particular. Whitaker makes the case that scientific advances are the result of intuition and creative insight on the part of researchers.

b) “The Creative Unconscious”: The non-conscious parts of our mind are the source of healthy, creative, productive behavior as well as “pathology.” It is a fallacy that only the conscious/rational is valid, and clinging to this idea limits science. The scientific process includes whole of the scientist and his (Whitaker was writing in the early 1950s) relationship to all of his data. Recognize the importance of the subjective experience of the observer.

2. Research in Psychotherapy

a) Methods of Research in Biological Science: In complex systems like the biological, individual cases become very important to observe, and generalization difficult.

b) Methods of Research in Psychotherapy: At the time of writing, research in this area was making some breakthroughs in areas previously intractable.

c) The Group Approach to Research Problems: It’s important to work in groups on research projects, but there are pitfalls in this area that pokes at the researcher’s deep beliefs and experiences. It requires intimacy, which takes time and commitment.

d)Problems of Communication: Written and even spoken communication is inadequate. Shared experiences are required.

e) Psychiatry and Psychotherapy: Art of Psychotherapy: Therapy is an art and intuitive and thus has a lot to offer to the science of psychiatry.

3. The Biological Basis of Psychotherapy: Whitaker makes a case for psychotherapy being a subset of biological studies, and proposes to adopt biological principles in the study of psychotherapy and the change process, which he calls “growth and adaptation.” [This reminds me of Wilber’s “differentiation and reintegration” process of development in Integral Psychology.]

a) Growth = orderly change with a direction as a fundamental process of organic systems. [Wilber calls this “development.”] Phases are “incubation and maturation.”

b) Energetics = The availability of energy depends on the development of the organism and “the tolerance of the system within which the organism functions.” [Italics mine.] He proposes that it is this interaction which provides the direction of growth.

c) Field Principles = The gestalt principle, “which has meaning only as an expression of homeostasis”: The whole is greater than the sum of its parts, but only when acting together in “sensitive dependence”

4. Adaptation: The “autotherapeutic function” of organisms, an internal change response to external or internal stress. Implies that pathology is a disruption of this growth. I’m disagreeing there, thinking “pathology” in this way is more like adaptive ability being overwhelmed by stresses. Or, as in Wilber, the adaptive ability itself matures, and the “pathology” is a result of developmentally inappropriate stresses, i.e. trauma.

a) The Problem of Repair: Organisms’ inherent self-repair ability can be seen as an immune response resulting in lasting adaptation. Physiological repair has many known limitations, but we are not yet aware of what limitations exist for psychological repair.

5. Catalyzed Repair: It is very important in our attempt to catalyze repair to not interfere with natural repair mechanisms! Remember to do no harm. The best we can do is augment natural healing processes.

6. The Community and Psychotherapy: Cultures have always had therapists, and their effectiveness seems based more on the person of the therapist than the soundness of their theory of change. Effective therapy must be congruent with the culture it exists in/serves.

7. Implicit and Explicit Psychotherapy: Whitaker defines therapy: “An interpersonal operation in which the total orgainismic adaptation of one individual is catalyzed by another individual in such a way that the patient’s level of adaptative capacity is increased.” Also, “Psychotherapy occurs whenever there results an increased actualization of the individual’s adaptative potential, with a corresponding decrease in the difference between what that person actually is and what he has the potential of being.” discusses the problem of defining “cure” in a therapeutic sense. Talks about therapy as partly a process of relegating to the unconscious those processes best handled by the unconscious, allowing the person to be more “natural.” Discusses importance of therapeutic relationship and the “patient’s” formulations of such. “Adequate therapy” much have a clear-cut ending where the client no longer needs the therapist.

a) Implicit psychotherapy is the therapy that happens, as defined above, “accidentally,” both in our everyday interactions and in interactions with therapists that therapists are not conscious of or the value of.

b) Explicit psychotherapy is the therapy that happens with mental health professionals, acting consciously on their body of knowledge/theory.

8. Dynamic Psychiatry and Psychotherapy: Psychiatry deals with the prevention and treatment of pathology. Psychotherapy is interested in the relationship of pathology to growth.

a) Psychoanalysis and Psychotherapy: Whitaker distinguishes the two (remember, this is 1953), giving props to analysis for being our most complete theory of personality, but also saying that analytic theory does not make analysis the necessarily best or only kind of therapy.

b) Psychotherapy and Time: Therapies can have two possible time vectors, the “genetic,” in which, since the past determines the experience of the present, the past is intensively reprocessed, and the “non-genetic,” in which, since present experience determines the future, the client’s relationship to theircurrent experience is altered or dealt with in such a way that ameliorates their relationship to both their past and their future. Whitaker calls this “experiential therapy,” which he calls “ahistorical,” “atemporal,” and says relies largely on how involved the therapist and client become in the moment. [I’m getting the sense by this time that experiential therapists basically think training in psychotherapy is just a way to become a really good “insta-friend.”]

B. Process

1. The Patient as a Person: Everyone is potentially a “patient,” so how do we differentiate between potential patients and actual patients?

a) The Genesis of a Patient: “Patient” defined as “a person who asks for help from the psychotherapist. Two fundamental ways psychotherapy is used are to help patient with a specific set of symptoms, or to “help the socially adequate” become more creative and well-integrated.

b) Barriers to Patient Status: First, fear of change. Second, fear of cultural rejection or retaliation, isolation.

c) The Social Therapist: This is my favorite of Whitaker’s ideas so far: Every person is a potential therapist for the people they interact with, and every interaction is a potential moment of therapeutic growth. People become patients of professional therapists because of a failure of their social-therapeutic community.

d) Culture: the Last Barrier: People have to pretend to be more mature than they are to make it in society. Going into therapy feels dangerous, then—giving up the facade of maturity. Also, the patient’s idea of what a therapist is is basically an amalgam of projections, which bring their own difficulties. All of these elements call up a patient’s protective mechanisms, which = “resistances.” The patient’s “growth impulse” must overcome these problems to come into therapy.

e) Conclusion: What is a “cured patient”? He gives a fairly long answer. “overcoming the inertia in the all-but-static growth process.” The patient experiences somethingdifferent which they take out into the world, questioning where they thought their limits were, more expressive, more capable of deep emotional bonds, “the capacity to demand, obtain, and participate in a new experience.” Reminds me of Johnson’s description of securely attached people—a safe haven encourages exploration.

The Process of Psychotherapy: How is therapy distinct from other social relationships, process-wise? Concludes that therapy has two basic processes, one for each session and one for therapy as a whole. This seems to come from psychoanalysis. He says three “segments” the middle of which is subdivided by 7 “phases.”

a) Outline of the Natural Divisions of the Process of Therapy:

1. Pre-Interview Segment: The events leading up to and before the first interview with the therapist, before the therapeutic relationship is established.

2. Analysis of Interview Segment:

a. The Symbolic and the Real In Therapy: The therapist and patient come together from different “realities” and during the process of the phases of the interview segment, both enter into the “essentially fantastic and symbolic” “therapeutic fantasy.” The patient (ideally) dips more fully, almost completely into the fantasy. Calls this “ the degree of symbolic involvement.” The relationship occurs cut-off from the rest of the world. In a way, the therapist is a guide through this experience, having “greater capacity for symbolic experience and unconscious functioning than the other,” because as far as I can tell thetherapist is more highly differentiated, though that’s not the word he uses.

b. The Loci of the Process: The therapeutic process is an unconscious-to- unconscious communication between the therapist and patient, similar to a mother-infant or lover relationship. It was difficult to understand his point here, but I also think he was really on to something—ahead of his time. Like he’s talking about the way brains change each other, described in A General Theory of Love.

c. Disquilibrium Dynamics: “Thevarious ways in which… transference projections emerge and are altered.” This gets complicated. Each participant in the therapeutic relationship has a “therapist vector” and a “patient vector” which my simplistic understanding is that the patient vector is the parataxic disortions of each person, and the therapist vector is the reality-seeing part. It looks like the general scheme (there are diagrams) is that the therapist’s becomes more and more of a therapist and the patient becomes more and more parataxic until the final state is that the patient’s therapist vector has increased dramatically. All disequilibrium dynamics are motivated (that is, therapy is moved forward by) anxiety.

1. shifts in and out of fantasy

2. alternation between needs of therapist and needs of patient.

3. transference/parataxic relationships are repetitive and are upset/changed by the maturity of participants.

d. Phases in the Interview Segment:This is a long, complex section that I don’t fully understand

1. Pre-symbolic phase—not much symbolic interaction. Still in the “real world.” this stage is an extrication from the real world.

I. Anamnestic—patient is pretending to be an adult for the benefit of now not present society.

II. Casting—patient starts filling symbolic needs by transference/fantasy.

2. Symbolic phase—involves transference, which he calls psychotic involvement or therapeutic psychosis. Reiterates that transference goes both ways. Symbolism → isolation of relationship. Fantasy. High level of communication, low level of anxiety.

III. Competitive—patient coming to see therapist as omnipotent

IV. Regressive—patient feels like baby.

V. Core–”therapist denies all reality.” Relation is “primordial parent” to “child-self.” “the essential therapeutic relationship, which patient uses to “work through” problems.

3. Post-symbolic phase—re-repression by client starts here.

VI. Testing—patient begins to see therapist as adult.

VII. Withdrawal—patient = adult. can be trouble for the still-involved therapist.

3. Endings of Therapy: Very important. Three types—positive, negative (patient leaves aggressively, defiantly), compromised (most common, most unsatisfactory—fatalistic withdrawal —therapist keeps patient dependent). Separation is motivated by:

1. patients denial of patient status

2. new insistance on status as separate person

3. acceptance of new therapeutic role by patient.

a) Post-Interview segment: Patient re-represses properly unconscious processes, defines themselves as unique individual who accepts positive restrictions of culture that do not interfere with vitality.

Anxiety and Psychotherapy

a) Bilaterality of Affect in Psychotherapy: The movement of therapy comes from the emotional participation of both patient and therapist, which vary in intensity proportionally.

b) Anxiety in Psychotherapy: Anxiety is unorganized affect, our infantile affective state. Infants use interaction to organize their affect resulting in an intrapersonal organization of affect (ego, basically, maybe also “personality”) which is the tool to deal with anxiety arising from the failure of a supporting interpersonal relationship. This is also the case with adults, though their intrapersonal organization can be much more mature than an infant’s. Positive anxiety arises from finding oneself in a relationship with the potential for growth (better, more mature organization of affect)–”New and unorganized affect is mobilized for growth.” Negative anxiety is basically a breakdown of defense mechanisms, and stems from “pathology of the intrapersonal organization of affect,” meaning a person’s organization breaks down, is inadequate, in a relationship, and that person loses security. Both kinds are “good” for therapy. Anxiety is the growing pain (or “integration pain”) of therapy. Whitaker relates these concepts to transference, countertranference, and symbolization. The last concept is how one person is able to tolerate the anxiety in a therapeutic relationship; the patient symbolizes the therapist (& vice versa, to a lesser degree, hopefully) which allows them to tolerate the “increased affect previously bound in neurotic mechanisms.

1. Anxiety Alterations in the Process of Psychotherapy: In the isolation of the sessions, patient loses their external controls of anxiety, so their anxiety increases. Patient’s anxiety organizes instead around the symbolic relationship with the therapist, whose “positive anxiety” is a buffer. This is a regression and scary for the patient. Therapist must maintain responsibility.

2. Anxiety and Communication: Nonverbal communication, to the extent that the therapist’s positive anxiety can match/outmatch the patient’s negative anxiety, organizes the free-floating affect (which is to say, negative anxiety, I think) therapeutically.

3. Functions of Anxiety for the Therapist: I didn’t quite get this section. He basically describes the interplay between positive and negative anxiety and how it relates to therapeutic impass, which is basically when both P and T are patients. Unmatched negative anxiety leads to repression and impasse. Look out for being tired at the end of a session. That is a sign of repression.

4. Anxiety and Aggression: A strong enough therapeutic relationship organizes anxiety into aggression, overcoming defense mechanisms. Aggression = an active attempt to get attachment needs met. Infants automatically become aggressive when feeling anxiety. In adults, it depends on the moment-to-moment perception of the therapeutic relationship. If a relationship is perceived as an opportunity to meet attachment needs, the resulting positive anxiety (from seeing the discrepancy between himself and his potential) produces positive aggression, organized therapeutically against the patient’s own repression. If a relationship is perceived as a threat to defenses, the resulting negative anxiety (feeling of threat) produces negative aggression, which is destructive and needs to be stopped. This process is at work in both patient and therapist.

The Therapist as a Person: Distinguishes 4 kinds of people. Nontherapists are administrators and have business functions. Social therapists are usually late-stage patients or early stage therapists, who have had some therapy and are aware of their own patient-needs and “who force growth in those around them.” Professional depth therapists have resolved most of their transference needs in treatment, can accept both therapist and patient vectors in their patients, and so gains therapeutically from each patient, which strengthens each patient’s capacity/maturity. Ideal therapists, usually outcasts (! Wonder if Whitaker was feeling like an outcast while writing?), can function as a professional depth therapist for any patient.

a) Community and the Therapist: The community projects as it will on therapists and they must be careful not to fall solely into that role-play. Must nurture professional, social, and individual self.

b) The Professional Therapist as a Social Self: Therapists need a non-therapist community of people who relate to them as a person and not a therapist.

c) The Development of the Therapist: Patient/nontherapist to Professional depth therapist is a continuum. Four facets of moving along it. 1) Being a patient is a big part of it. Experience as a patient. 2) Personal maturation. 3) Experience as a therapist leads to eventually abandoning training. 4) Professional training—important but dicey. Can stifle the therapeutic intuition. The most important part of training is concurrently receiving therapy. Dydactic training is best delayed until significant patient and therapist experience is accrued and must always be secondary to the therapist’s experience as a patient and therapist.

1. Growth in Treating Patients: The therapist grows from treating patients, like parents grow up by raising children. No therapist has approached the limits of maturity.

2. Continuing Motivations of the Depth Therapist: Partly residual infantile fantasies which at best can help understand patients. Partly areas of “minor transference difficulties” which patients poke at and facilitate therapist’s growth. Also, therapist’s own therapy has left superego (internal parent) unrebuilt, which is done with patients. Ultimately, therapist gets to relate to others and himself (body image) with freedom and maturity. That is the real goal.

3. Body Image: Growing up and therapy fragment the experience of self—the distortions of infantile fantasies are corrected by therapy, but things are not reintegrated without performing therapy. Like parents who grow up by parenting.

Patient-Vectors in the Therapist

a) The Concept of Counter-transference: Everyone has transference—basically infantile feelings. Countertransference has been called that transference of the therapist which buys into his patient’s specific transference, undermining the therapeutic process. Whitaker feels that therapy is largely moved by the therapist’s emotion, so distinguishes between “mature countertransference” and “unconsidered and infantile counter- transference.”

b) Patient-Vectors and Therapist-Vectors: In each moment in therapy, whoever is responding in the most mature way is acting as the therapist. Patient-vectors are child- demands for parental attention. In good therapy, the therapist is usually acting on Therapist-vectors and the patient on Patient-vectors. The occasional switch is good for P to exercise adult-development, but sometimes the switch interferes with therapy—this is when the therapist’s P-vector is accurately called countertransference. P-vectors = intrapsychic growth needs. If T is adequate to a particular relationship, the Patient’s P- vectors will make himself well. (This reminds me of Satir, finally. It’s funny how those two get lumped together.) Therefore, It is the therapist’s job, not the patient’s, to resolve impasse. Do not blame “resistance.” It is super-important that T brings his whole selfincluding his P-vector immaturities to the room. Doing so does not guarantee therapist’s adequacy, but it is the best chance—othewise, P feels rejected: “We believe that the child feels rejected only when he senses a difference between what the parent could be as a person and what he actually is.” p. 164

c) Bilateral Character of Therapy and Patient-Vectors: Therapeutic impasse can often only be resolved by the therapist bringing his P-vectors overtly to the patient. This section has the first mention of “brief therapy”–patients do not seem to need continuity from hour to hour or minute to minute in therapy.

d) Categories of Patient-Vectors: There are categories, as listed below.

e) Avoidance of Therapeutic Relationship as a Category of Patient-Vector:Since the Therapeutic process is symbolic, not “real,” when the therapist engages in P’s “real” rather than symbolic problems it make P feel rejected. Avoiding P’s and T’s symbolic needs by “staying real” or “objectivity” is a rejection of the therapeutic process by the therapist. It becomes clear later, I think, that by symbolic, Whitaker basically means emotional.

f) Transference as a Patient-Vector in the Therapist: Patient can usually handle a therapist projecting inner-siblings and sometimes inner-parent on them, but never primordial parent. Also, a description of the classic “transference cure,” where the therapist projects his inner child on the patient and calls the patient “cured” when the patient acts “correctly” as that child. That child/patient will always remain dependent on the therapist.

g) Non-Transference (Sliver) Patient-Vectors in the Therapist: These are where the therapist’s experience with a different patient, something in the therapist’s life, or overenthusiasm for a certain technique, clouds the therapist’s thinking about the patient. Necessary to some degree for motivation, but can lead to impasse.

h) Resolution of the Impasse: Impasse results from the therapist’s denied patient-vectors causing him to avoid moving towards resolution of the therapeutic relationship, in the unconscious hope of satisfying his own patient-needs with the patient. Impasse is resolved by greater involvement in the relationship, not by withdrawal. Tough impasses need a 3rd person involved—supervision for the therapist, a cotherapist on the case, or therapy for the therapist.

i) Diagrams: Chapter 13 ends with ten somewhat mystifying diagrams grouped under t he following categories: “Therapist satisfies his own patient needs in his relationship with the patient,” “Therapist refuses to recognize the bilateral character of the transference relationship,” and “Therapist refuses to recognize patient’s immaturity, maturity, or his growth.”

Restatement of the Problem of Psychotherapy: Based on three fundamental principles of human behavior: 1) growth capacity can overcome trauma and emotional malnutrition, 2) experiential (Id as opposed to Ego) therapy uses the currenterxperience to modify and integrate the way past experiences are organizing present experiences (reminds me of LF), and 3) psychological homeostasis protects patient from therapist’s technical and maturaty inadequacies. Restates the necessity of a reciprocally but not equally therapeutic relationship. The therapeutic relationship is an externalized “good parent” intra-psychic relationship, allowed by the isolation of therapy from reality, freeing IP from cultural roles. The maturity of the therapist gives space for increased positive anxiety in IP to accelerate growth using the emotional relationship.

Techniques

Some Techniques in Brief Psychotherapy: “A technique is an interpersonal operation deliberately used by the therapist, the function of which is to transpose social, latent affect in both participants into deeper, manifest affect in order to catalyze the affective and symbolic process of psychotherapy.” “A technique is effective if it induces personal and deep feeling in the relationship, producing relatedness which is no longer deliberate and conscious, but spontaneous and integrated.” Techniques are more important for the beginning and ending phases of therapy, as the middle phase tends to take care of itself.

a) Techniques of Administration in Therapy: It is better if the therapist does not do administrative work with the patient, even social work type stuff, as this can impede forming a symbolic relationship.

b) Techniques in the Beginning Phase of Therapy: “The abuse of techniques in therapy stems most fundamentally from using the devoid of personal feeling and real affect, but secondarily stems from their use at an inappropriate time.” Techniques for the beginning phase are to isolate the relationship from reality and facilitate the transition to a symbolic, fantasy relationship (which I’m basically reading as a deeply emotional relationship). He discusses many ways to isolate the relationship, including meeting in the same place (not the patient’s house—somewhere unfamiliar), being very strict about the therapy hour, and refusing to be interrupted by phones etc and refusing to engage reality-based content, history, or questions about the therapists “real” life. He recommends focusing on data from the unconscious such as slips of the tongue and posture, and even more in the therapist than the patient. “The therapist needs only the conviction that everything the patient says after the early stages has symbolic portent for their relationship.” Implicit understanding is more important than explicit, and in fact says to fail to respond to any “real” material” to limit the “patient’s energies to the fantasy area.” Do this with firmness. It is particularly effective to use language from childhood, religion, and body image/somatic events, all symbolically interpreted.

c) Techniques in the Symbolic Phase of Therapy: Techniques in this phase mostly just “contaminate” the therapeutic relationship. Whitaker talks seriously about holding, rocking, feeding, and spanking patients(!). But only if the therapeutic response is inadequate. In the final, “core” stage of the symbolic phase, there are no techniques. T and P relate symbolically to each other as nursing mother and infant.

d) Techniques in Ending: Techniques become important again with ending. Whitaker lists 13 ways to tell that the ending phase is here, basically the patient brings reality back in, with more maturity.

e) Techniques Involved in the Testing Stage: The testing stage is the first part of ending. Basically, start refusing fantasy vectors, introduce reality, talk about ending. Show faith in patient’s new maturity.

f) Techniques and Communication in Therapy: “…all [techniques] function through increasing and clarifying the inter-subjective communication between the participants in psychotherapy.” Emphasizes use of non-verbal communication.

g) Technical Orientations Useful Throughout the Process:

                  1. Transference and Emphasis on the Present Relationship:In Whitaker’s “brief depth therapy,” the therapist’s interpretations of the patient’s transference projections are implicit and based on the present moment and relationship. (Sounds a lot like Yalom.) “He alters the nature of the patient’s response, not by an intellectural or ego correction, but by way of his own emotional and personal participation in the relationship.”
                  2. Insistence on Face-to-Face Relationship: No lying on a couch. Therapist does not relay on “objectivity,” but on own maturity and the adequacy of his own therapy (sounds like Bowen). Encourage direct eye contact.
                  3. The Use of Silence as a Technical Aid: Silence helps deepen patient’s transference at various stages. Also advocates actually sleeping at times during session.
                  4. The Use of Aggression as a Technique in Psychotherapy:Aggression is useful but it is the technique most likely to be abused. “The patient learns emotionally, because of the therapist’s active participation in this relationship with him, that aggression is possible without the loss of the underlying positive feeling which unites the patient and therapist.” p. 224
                  5. The Use of Physical Contact as a Technique: Useful and can be problematic, as above. Suggests holding crying patients and bottle feeding.
                  6. The Joint Fantasy Experience as a Technical Aid in Brief Psychotherapy: If therapist can verbally participate in P’s fantasy, it deepens the relationship.

f) Pitfalls of Psychotherapy:

                  1. Do not diagnose. “The aim of the young therapist in the beginning phase of therapy should be to explicate the patient’s needs, never his pathology.”
                  2. Do not accept acute anxiety as an emergency.
                  3. Never deliberately slow the process of therapy. “The process seeks its own rate and technical intervention on the part of the therapist is usually out of his own pathology and dynamically dangerous.”
                  4. Never compromise your “self,” social, or professional life for a client. Refuse “to see the patient at times that would seriously interfere with the satisfaction of [therapist’s] own living.”
                  5. Never verbalize without affect.
                  6. Do not interpret content. Rather, “relate, as a person, with feeling to each symbol presented by the patient.”
                  7. “Never deny the least fragment of ending in the patient. Verbalize ending cues received. “The earlier the ending, the more effective is psychotherapy. Never transfer a patient to another therapist.

g) Technical Aids in the Resolution of the Impasse: Assume the patient’s readiness to end. Then use silence and/or aggression. If you cannot make progress, let the patient initiate ending therapy, so he ends with strength.

h) Technical Aids in the Post Ending Relationship: If you meet a patient in the community after therapy is complete, as long as you know there are other resources for them to use in the community besides you, “feel free to spontaneously participate on a social level, and deny any symbolic role, thus letting the chips fall where they may. I thus asserting his right to be areal person, [the therapist] simultaneously gives expression to his faith in the patient’s capacity to be a real person.

Depression in Couples: Literature Review and a Metaframeworks Approach

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[First published on Nathen’s Miraculous Escape, January 7, 2011.]

Nathen B. Lester

University of Oregon

Abstract

This paper a brief overview of the evidence and discourse about depression, focusing on its occurrence, dynamics, and treatment in couple relationships.  This is followed by an introduction to Breunlin, Schwartz, and Mac Kune-Karrer’s metaframeworks model for therapy and its possible application in the treatment of depression in couples.

Keywords: depression, couples, couples therapy, metaframeworks

Depression in Couples:

Literature Review and a Metaframeworks Approach

In the last few decades, depression has become an obsession in the US.  We are flooded with ideas about depression from television shows, magazine articles, self-help books, celebrity therapists, theoretical articles, feminist treatises, pharmaceutical advertisements and press releases, research results from biological, clinical, epidemiological, psychological, and sociological perspectives, plus critiques and meta-analyses of that research.  This obsession is not surprising, considering the medical, mortality, and employment costs of the condition are well above $80 billion per year and climbing (Greenburg, Kessler, Birnbaum, Leong, Berglund, & Corey-Lisle, 2003), considering the evidence that prevalence rates are increasing and age of onset is decreasing with each generational cohort (Craighead, 2007), and considering what an unpleasant and dangerous condition it is.  The World Health Organization has predicted that in the next 15 years depression will move from the fourth most disabling disease in the world to the second, behind only obesity/diabetes (Sapolsky, 2009).

In my practice as a couples and family therapist in training, depression is just as common a complaint as the ubiquitous “communication problems,” meaning at least one partner in every couple I have seen so far has considered themselves clinically depressed.  This paper represents my attempt to delve into the data and conversation about depression, how it is treated in couples, and to approach it using the perspective of metaframeworks, as put forth in Breunlin, Schwartz, and Mac Kune-Karrer’s (1997) Metaframeworks: Transcending the Models of Family Therapy.

Depression

What Do We Know About Depression?

We know how we define it. In the mental health profession, if someone “has depression,” we mean that they meet the criteria in the current edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) for Major Depressive Disorder.  That means the daily presence of a depressed mood, anhedonia, and at least three of the following six symptoms for at least two weeks: (a) weight loss or gain of at least 5%, (b) insomnia or hypersomnia, (c) observable agitation or slowed movement, (d) fatigue, (e) feelings of guilt or worthlessness, (f) subjectively or objectively decreased cognitive ability, and (g) suicidality. Additionally, these symptoms must  impair functioning in some significant way, must not be the result of an illness or drug, and must not be the result of bereavement—that is, must not occur only within two months of the loss of a loved one (American Psychiatric Association [DSM-IV-TR], 2000).

Additionally, we define depression in terms of the number of depression-indicating responses to surveys, like the Hamilton Rating Scale for Depression (HRSD) (Hamilton, 1980) and the Beck Depression Inventory (BDI-II) (Beck, Steer, Ball, & Ranieri, 1996).  The HRSD and BDI have participants rate symptoms, mostly DSM-IV-TR criteria, on Likert scales between none and severe.  They produce numbers which are compared to predefined cutoffs for no, mild, moderate, severe, and (for the HRSD) very severe depression.

We know quite a few correlates. Depression is associated with intense affect, especially sadness and anxiety, as well as physical pain, addiction, suicide, and social problems such as divorce, unemployment, and truancy (DSM-IV-TR, 2000).  It is also correlated with internal attributions of negative events and external attributions of positive events (Pinto & Francis, 1993).  Of the 17% of US residents who qualify as depressed at some point in their lives, between 10.5 and 18 million people at any one time, two-thirds are female (Craighead, Sheets, Brosse, & Ilardi, 2007), though the DSM-IV-TR reports that rates are even between boys and girls before puberty. The DSM-IV-TR also claims that there are no difference between those in different ethnic, socioeconomic, educational, or marital categories (DSM-IV-TR, 2000), though there is some evidence for a correlation with poverty (Kim, 2008; Vilhjalmsson, 1993) and menial labor (Bonde, 2008).

Major childhood stressors such as physical, emotional, and sexual abuse, witnessing domestic violence, separation, or divorce, or drug abuse, criminal activity, mental illness, or suicide in the household significantly increase rates of depression in adults (Anda, Whitfield, Felitti, Chapman, Edwards, Dube, & Williamson, 2002; Chapman, Anda, Felitti, Dube, Edwards, & Whitfield, 2004; Edwards, Holden, Anda, & Felitti, 2003).  Major stressors in adulthood, especially those related to social rejection, can also precipitate depression (Kendler, 2003; Kessler, 1997; Slavich, Thornton, Torres, Monroe, & Gotlib, 2009).  The highly religious appear to be more prone to depression, though more resilient against it once it occurs (Dein, 2006; McCullough & Larson, 1999).  Depression is more common among  people with major medical conditions (DSM-IV-TR, 2000).

There are no biological tests for depression (DSM-IV-TR, 2000).  There do appear to be a few biological correlates, however, including atrophy of the hypothalamus (Patterson, Albala, McCahill, & Edwards, 2010), increased stress-hormone levels, decreased growth-hormone levels (DSM-IV-TR, 2000), and a short allele of the  5-HTT gene (Caspi, Sugden, Moffitt, Taylor, Craig, Harrington, McClay, Mill, Martin, Braithwaite, & Poulton, 2003).  Being related to a person with depression increases your chances of becoming depressed as well, which is suggestive of a biological correlate (DSM-IV-TR, 2000).  Each of these factors correlate to a significant degree with incidence of depression, but none to the extent that they are candidates for a cause.

By far the strongest biological correlation with depression we know of so far are abnormalities in electroencephalogram (EEG) readings during sleep.  The DSM-IV-TR reports a correlation of 40-60% in outpatient groups and up to 90% for inpatients (2000).  Also, complete sleep deprivation has been shown to entirely alleviate symptoms of depression in over half of participants (Wu & Bunney, 1990).

Another category of correlates is treatment outcomes.  These fall into three general categories–therapeutic, somatic, and placebo–most of which are basically equivalent in their efficacy, which is to say they seem to have a lasting positive effect somewhere around half to two-thirds of the time (Patterson et al., 2010).  The evidence that we have about therapeutic treatment comes largely from clinical tests of variants of cognitive and behavioral therapies, and finds these therapies to be effective to the same degree (Wampold, 2001).  In somatic treatments depressed people take medication, have their brains shocked, have their sleep interfered with, or, in the most extreme cases, their brains operated on.  In a placebo treatment depressed people eat sugar pills which they believe might be medication.  There is evidence that some medications work significantly better than placebos for those with severe or very severe depression (Fournier, DeRubeis, Hollon, Dimidjian, Shelton, & Fawcett, 2010).  There is evidence that reducing REM sleep over time can improve symptoms of depression to the same or somewhat better than a placebo (Rieman, Berger, & Voderholzer, 2001), and there is evidence that electroconvulsive therapy (ECT) is the most effective treatment of all, at approximately 80% response rate (Patterson et al., 2010).  There is also evidence that stereotaxic anterior cingulotomy reduces the symptoms of depression (Ballentine, Bouckoms, Thomas, & Giriunas, 1987; Sapolsky, 2009; though see Cohen, Paul, Zawacki, Moser, Sweet, & Wilkinson, 2001).

What Do We Think About Depression and How Do We Treat It?

How we think about and treat depression is shaped greatly by our theoretical perspective; cognitive therapists emphasize the role of thinking  and psychiatrists emphasize the role of neurobiology.  In the face of the evidence, however, very few theorists or clinicians still believe there is a single, causative factor for depression.  Most, instead, believe some version of the diathesis-stress model, which holds that depression is the result of an interaction between biological factors, usually genetic and/or epigenetic, and some form of environmental stress, such as trauma or loss (Monroe & Simons, 1991; Sapolsky, 2009).

That said, each school of thought does think about and treat depression differently.  Psychiatrists and other medical doctors, for example, tend to emphasize the diathesis side, and see depression as primarily a more-or-less mysterious biological disease, caused by a disregulation of neurotransmitters or other hormones, or some other wiring or firing malfunction of our neural networks.  These clinicians prescribe somatic therapies based on their theoretical training.  The vast majority of patients receive medication that is thought to increase the effects of seratonin on the brain (SSRIs), and most of the rest receive one of a couple older classes of medications, thought to act on norepinepherin or on all monoamine neurotransmitters (Olfson, Marcus, Druss, Elinson, Tanielian, & Pincus, 2002; Unutzer, Katon, Callahan, Willians, Hunkeler, Harpole, Hoffing, Penna, Noel, Lin, Tang, & Oishi, 2003).  Somewhere between 8 and 60% receive psychotherapy, depending on their age (older patients get less therapy) (Olfson et al, 2002; Unutzer et al., 2003).  By comparison, other somatic treatments, such as electroconvulsive therapy, vagal-nerve stimulation, REM-deprivation therapy, light therapy, and changes in diet or exercise, are prescribed for only a tiny fraction of patients.

Those operating from the standpoint of a psychotherapeutic modality, on the other hand, tend to focus on the stress side of the diathesis-stress model, and each model has its favorite stressor.  Cognitive therapists, for example, see depression as the result of extreme, inaccurate, and pessimistic thoughts and beliefs, and treat it by helping clients recognize and counteract these distortions (e.g. Beck, 1976; Ellis, 1998).  Behavioral therapists see depression as essentially as a bad habit resulting from environmental rewards for depressive behavior and punishments for non-depressive behaviors, which are best treated by reversing that reinforcement system (e.g. Kanter, Cautilli, Busch, & Baruch, 2005).  The many, many varieties of psychodynamic therapy all have in common the beliefs that problems come from clients’ internal, unconscious conflicts, and that they are best worked out in a conversation with a therapist that leads to insight.  Different schools of psychodynamic therapy each have different emphasis, however, that  affect how they see and treat depression.  A psychoanalyst might see depression as the result of early, formative experiences that caused the client to turn their anger inward into guilt, and ask the client to free-associate and talk about dreams over a period of years, offering periodic interpretations.  Humanistic psychodynamic models such as Rogers’ client-centered therapy, Perls’ Gestalt therapy, and Yalom’s existential therapy focus more on how clients heal, in the present moment, in the presence of a therapist who is behaving authentically, than on how they become troubled.  A client-centered therapist believes that depression is best ameliorated by the client coming to trust the unconditional positive regard of the therapist (e.g. Rogers, 2003).  A Gestalt therapist believes that they can help by challenging the client to behave with complete authenticity (e.g. Perls, 1973).  An existential therapist believes that genuinely coming to grips with the reality and inevitability of suffering and death are the most helpful (e.g. Yalom, 2009).  One psychodynamic approach–psychodynamic-interpersonal therapy–was designed to treat depression.  Like other psychodynamic approaches, it focuses on emotions, interpersonal experiences, and the therapeutic relationship–but it also incorporates Bowlby’s attachment theory and typically uses few enough sessions to be called “brief therapy” (e.g. Klerman, Weissman, Rounsaville, Chevron, & Rounsaville, 1984).

Couples and family therapists have many of their own systemic views of the stress side of the diathesis-stress model.  Confronted with a client complaining of depression, an MRI-style brief therapist, for example, would first look for problematic, outdated rules that the family system is acting under, in the form of their attempted solution for the problem.  They would design an intervention that represented as much as possible the opposite of the family’s attempted solution, perhaps by prescribing depressive behavior (e.g. Fisch, Weakland, & Segal, 1982).  A structural family therapist would imagine that depression is the result of inappropriate power alliances between, for example, a parent and child against a second parent.  They would design a behavioral intervention to realign the family hierarchy, such as advising the parents to go out on a secret date (e.g. Minuchin & Fishman, 1981).  A strategic therapist might also see depression as the result of outdated rules or inappropriate power alliances, but also looks for how the depression might be serving a function for the family system—the interpersonal payoff.  If the latter is suspected, a strategic therapist might prescribe an Ericksonian ordeal, intended to make the problematic behavior more difficult to maintain than non-problematic behavior (e.g. Haley, 1984).

An experiential family therapist would find the depressogenic stress in a client’s low self-esteem, and attempt to remedy it by modeling and by leading communication exercises designed to increase authentic communication (e.g. Satir, 1983).  For a Bowenian intergenerational family therapist, stress is the result of a lack of differentiation, meaning anxiety and rigidity of behavior in response to external or internal emotional pressures.  To help increase a client’s differentiation, a Bowenian therapist explores the quality of extended-family relationships and interrupts emotional triangulation, while maintaining their own differentiation (e.g. Nichols & Schwartz, 2008).

A feminist family therapist looks for and tries to resolve stress in the form of gender- or culture-based power differentials (e.g. Leupnitz, 1988).  A solution-focused family therapist believes that stress is the result of a focus on problems, and attempts to alleviate it by focusing on and enhancing exceptions to the problems (e.g. deShazer, 1988).  A narrative family therapist sees stress as the result of clients having internalized a negative discourse about themselves from the dominant culture, and attempts to alleviate it by finding examples in the client’s life that are contradictory to that discourse and re-author a new story.  Narrative therapists also rely on a technique called externalization, where a client’s problem is given a name and the client comes to see it as not part of their self (e.g. White & Epston, 1990).

Emotionally-focused couple therapy (EFT) finds stress is in unmet attachment needs for safety, proximity, and connection.  Therapy consists of an emotional negotiation of what gets in the way of asking for and responding to requests for attachment needs, especially in relationships with a pursue-distance dynamic (e.g. Johnson, 2004).  In Gottman’s couple therapy, the stress resulting in depression is an internal working model of worthlessness and lack of control, and therapy consists primarily of developing a new story about the self, in conversation, creating new and different kinds of positive interactions (e.g. Gottman, 1999).

One other school of thought about depression does not come along with a therapeutic modality, but is worth mentioning.  Evolutionary theorists have recently suggested that while depression is unpleasant and dangerous, it may be an adaptive behavior.  There is evidence to suggest that depression is essentially a physiological state designed to enhance our analytic-rumination process in the face of complex social problems (Andrews & Thomson, 2009).  In other words, depression may help us concentrate on and think about difficult interpersonal situations.

Depression in Couples—Two Literature Reviews

Social psychologists, apparently spurred on by an insatiable desire to understand the minute details of the relationship between depression and marital distress, have amassed a mountain of evidence, from the obvious to the baffling, about depression in couples and how depression affects couples’ and family’s dynamics.  The simple version of the story is that, while complicated by gender and many other factors, there is a relationship, and it is not good.  Depression in couples is not good for the couple, the individuals in the couple, or the children that come from the couple:

Depression correlates with dysfunctional marital interactions and marital distress (Gabriel, Beach, & Bodenmann 2010; Rehman, Ginting, Karimiha, & Goodnight, 2010), but there is also evidence that it does not contribute in any unique way to a couple’s communication (Eldridge, Jones, Sevier, Clements, Markman, Stanley, Sayers, Sher, & Christiansen, 2007).  Depression is negatively correlated with relationship satisfaction (Cramer & Jowett, 2010) and positively correlated to violent and abusive behaviors in relationships (Vaeth, Ramisetty-Mikler, & Caetano, 2010).  Depression reduces dyadic adjustment (Tilden, Gude, Hoffart, & Sexton, 2010), is less likely to remit in the presence of dyadic discord (Denton, Carmody, Rush, Thase, Trivedi, Arnow, Klein, & Keller, 2010), and predicts low relationship quality (Papp, 2010).  Depression is a precursor to divorce (Doohan, Carrere, & Riggs, 2010).  Depression hinders attachment in couples (Mehta, Cowan, & Cowan, 2009).  Depression in one spouse predicts depression in the other (Goodman & Shippy, 2003) (but not in dating couples (Segrin, 2004)).  Depression in either partner predicts marital dissatisfaction (Whisman, Weinstock, & Uebelacker, 2002).  Depression can trigger relationship problems/marital distress, and relationship problems/marital distress can trigger depression (Reich, 2003; Mead, 2002).  Distressed relationships increase depression relapse (Whisman & Schonbrun, 2010).

There is some evidence about what might help. A sense of enduring control in a relationship, for example, may buffer against depression (Keeton, Perry-Jenkins, & Sayer, 2008), and marital satisfaction is higher whether or not there is depression if your spouse likes you (Sacco & Phares, 2001).  And there is some evidence about how the interactions work.  Evidence exists, for example, that marital discord and depression may be mediated by hopelessness and blame (Sayers, Kohn, Fresco, Bellack, & Sarwer, 2001).  Partners’ depressive symptoms tend to become more similar, which may be driven by their coping styles becoming more similar (Holahan, Moos, Moerkbak, Cronkite, Holahan, & Kenney, 2007).  Depression may cause marital dysfunction and psychological distress by reducing the empathic accuracy of the depressed partner—that is, because they imagine incorrectly that the non-depressed partner feels as badly as they do (Papp, Kouros, & Cummings, 2010)–but there is also evidence that depression does not affect empathic accuracy in couples (Cramer & Jowett, 2010).  It is far more common for people seeking help for depression to have a relationship in distress than for those seeking help for relationship distress to have depression (Atkins, Dimidjian, Bedics, & Christensen, 2009).

Many of the findings are gender-specific. The effects of depression on relationship problems and vice versa are greater for women than men (Reich, 2003).  For women, neuroticism increases the effect of marital distress on depression, but for men it decreases it (Davila, Karney, Hall, & Bradbury, 2003).  Negative marital interactions make women’s but not men’s depression worse if they don’t have confidence in the relationship (Whitton, Olmos-Gallo, Stanley, Prado, Kline, St. Peters, Markman, 2007).  Husbands’ depression predicts wives’ depression, but not vice versa (Kouros & Cummings, 2010).

Finally, there is a lot of evidence that depression in parents is not good for their children, correlating with less secure attachment as infants (Martins & Gaffan, 2000), for example.  Parental depression affects  children’s adjustment to school more than parenting ability does (Cummings, Keller, & Davies, 2005). And depressed parents tend to have more depressed and disabled adult children (Timko, Cronkite, Swindle, Robinson, Turrubiartes, & Moos, 2008).

Treating Depression With Couples Therapy: The Evidence

Most of the research on treating depression with couples therapy has involved behavioral marital therapy (BMT).  I found ten empirical studies looking at BMT for depression.  Five of them compared BMT to individual cognitive or cognitive-behavioral therapies (CT or CBT).  In three of those, BMT was equivalent to individual therapy in its amelioration of depression, but more than individual therapy, it reduced marital discord  (Beach & O’Leary, 1986), increased marital adjustment for depressed women (Beach & O’Leary, 1992), and increased marital satisfaction (Emanuels-Zuuveen & Emmelkamp, 1996).  In the fourth, BMT reduced depression as much as individual CT, but only for distressed couples, not non-distressed couples (Jacobson, Dobson, Fruzzetti, & Schmaling, 1991), and in the fifth, a “behavioral spouse-aided therapy” for depression was equivalent to individual CBT but had no boost for marital satisfaction (Emanuels-Zuurveen & Emmelkamp, 1997).  In a sixth study, BMT reduced wives’ depression significantly more than a wait-list control, with 67% of participants improved and nearly half recovered three months later.  Additionally, wives’ marital satisfaction increased and husbands’ psychological distress decreased (Cohen, O’Leary, & Foran, 2010).  In the seventh study, two-thirds of depressed women improved with BMT, and nearly half recovered (Cohen, O’Leary, & Foran, 2009).  In the eighth, two-thirds of depressed spouses of both genders recovered from depression with BMT (Sher, Baucom, & Larus, 1990).  In a final study, depressive symptoms actually predicted positive outcomes for BMT (Jacobson, Follette, & Pagel, 1986).

Three studies looked at cognitive-oriented approaches.  CBT family therapy for depressed parents significantly alleviated parental depression, but the nearly-large effect size (d = .49) at six months fell to a small-to-medium effect size (d = .26) at a 12-month follow up (Compas, Forehand, Keller, Champion, Rakow, Reeslund, McKee, Fear, Colletti, Hardcastle, Merchant, Roberts, Potts, Garai, Coffelt, Roland, Sterba, & Cole, 2009).  Cognitive marital therapy reduced depression as much as individual cognitive therapy for depression and was a little better for severe depression (Teichman, Bar-El, Shor, Sirota, & Elizur, 1995).  Finally, seven sessions of cognitively-oriented family therapy produced substantial and long-term recovery from depression in depressed female parents and small recovery rates for depressed male parents (Beardslee, Wright, Gladstone, & Forbes, 2007).

Five more studies looked at a variety of other couples treatments.  An “integrative approach,” combining systemic, narrative, cognitive-behavioral therapies and psychoeducation, for residential adults with depression showed improvement with significant and large effect sizes (Tilden, Gude, Sexton, Finset, & Hoffart, 2010).  A “coping-oriented couple therapy” matched CBT and individual interpersonal therapy for improving depression (Gabriel, Bodenmann, Widmer, Charvoz, Schramm, & Hautzinger, 2009).  Systemic couples therapy was at least as effective as drug therapy, and more acceptable to participants (Leff, Vearnals, Brewin, Wolff, Alexander, Asen, Dayson, Jones, Chisholm, & Everitt, 2000).  EFT was also as effective as drug therapy for depression (Dessaulles, Johnson, & Denton, 2003).  A trial that included but did not separate the effects of integrative, systemic, psychodynamic, Gestalt and behavioral therapies reduced depression by about half in couples with infidelity and by a quarter in couples without infidelity (Atkins, Marin, Lo, Klann, & Hahlweg, 2010).

Finally, a meta-analysis in 2008, using seven of the studies mentioned above and ruling many others out for various reasons, found that couples therapy and individual therapy are equally effective treatments for depression and that couples therapy has the additional benefit of relieving distress in couples, but that there is so little evidence and it has been produced and described so poorly that it is too early to recommend couples therapy as a treatment for depression 46 (Barbatto & D’Avanzo, 2008).

Metaframeworks

Metaframeworks is an approach to therapy synthesizing ideas from many different models of family therapy, plus postmodern philosophy, multiculturalism, feminism, and Bateson’s interpretation of Bertalanffy’s general systems theory.  It was developed by family therapists and theorists Breunlin, Schwartz, and Mac Kune-Karrer, and initially presented in their 1992 book,Metaframeworks: Transcending the Models of Family Therapy.  (All information about information presented below about metaframeworks, however, is based on my interpretation of their second, revised, edition of that book, published in 1997.)  Breunlin and colleagues propose that humans suffer as a result of constraints upon their intrinsically resourceful and self-actualizing nature.  These constraints exist on any of several levels of organization: biological, individual, relational, familial, communal, and societal.  Constraints also exist in any of several forms, which give the names to the six metaframeworks: mind or “internal family systems” (IFS), sequences, organization, development, multicultural, and gender.  The level and form that constraints exist on and as interact to form a web of constraints, which can be conceptualized as in Figure 1 (see appendix).  In this conception, clients’ problems can exist as a result of constraints at any combination of points in the web.  The job of the therapist is, in a flexible, collaborative, and intuitive process, identify and release the constraints that are not allowing clients to resolve their problems.

The Role of Systems Theory

Systems theory is a body of thought concerned with “whole” patterns of organization and interaction and the relationships between them.  In metaframeworks, those wholes (calledholons) are characterized as a distinct network of parts which interact recursively by a set of organizing rules that allow for both adaptation and stability.  Holons exist and interact both in parallel and in hierarchies. For example, the organs in a human body are each holons, interacting with the other organs in various ways. At the same time, each organ is also interacting with the holons at higher (the whole body and “up”) and lower (individual cells and “down”) levels of organization.  The nature of all of these interactions is said to be recursive, meaning the action of each part of each whole at each level of organization affects the actions of every other part of every other whole, at every other level or organization.
A metaframeworks-oriented therapist uses the lens of systems theory to work towards a rich, holistic view of their clients, and to keep in mind all of the levels of organization that constraints might exist on, and how those levels might interact.  An individual client might be constrained by a biological disease process, for example, or an oppressive economic system.  Additionally, the disease, the person, and the economic system all interact with each other, each one possibly generating, regulating, or supporting the others in different ways.  Without a systemic view, we miss might these interactions and, therefore, possible points of intervention.

Epistemology and Assumptions

A metaframeworks-oriented therapist works grounded by a view of reality, health, human nature, and change based on four assumptions.  First, they take a middle-of-the-road constructivist stance, called perspectivism.  That is, our senses and thinking do produce maps of a reality that exists independently, but our maps are always limited by our perspectives—our senses, beliefs, and cultures.  Furthermore, some maps are more accurate than others.  Second, it is more accurate and useful to think of human problems in terms of constraints than pathology.  That is, if we assume that a client is suffering or dangerous because we have yet to identify and resolve factors that are holding them back from their potential, we are much more likely to help them than if we assume that they are evil or broken.  Third, healthy systems are characterized by balance, harmony, and leadership.  It is the job of certain parts of a system to provide flexible coordination and regulation for that system, and lack thereof indicate that the leadership of the system is acting under constraints.  Likewise, escalation, rigidity, and failures to adapt or meet the needs of some parts of a system are indications of constraint.  Fourth, metaframeworks-oriented therapists believe that intrapsychic work with the subpersonalities of an individual client is often important to resolve constraints.  The rejection of inner work by behaviorists and early family theorists limited the ability of therapists to identify and resolve constraints.  Furthermore, subpersonalities are organized and interact in the same way that parts of other systems are organized and interact:  They are ideally balanced and harmonious, and have strong leadership in the Self, which is similar to Freud’s concept of ego, but they can become polarized, extreme, or rigid and thus constraining.

Using Metaframeworks

Each of the metaframeworks is a perspective from which to look for and at constraints at any level of organization.  Each has its own conceptual framework, vocabulary, and can suggest different hypotheses and interventions.  The metaframeworks approach uses these perspectives with a blueprint for continually and collaboratively expand and fine-tune therapy for each client.

Internal family systems. IFS is a model of therapy as well as a metaframework.  As a metaframework, it is essentially a psychodynamic theory, positing the existence of a Self plus any number of subpersonalities, each filling a specific role.  We may have a creative part, a cautious part, an adventurous part and so on.  IFS holds that trauma can cause a breakdown in the organization of our subpersonalities.  Instead of balanced and harmonious parts lead by a strong self, some parts can become dissociated and others can come to overshadow the Self.  A typical result of trauma is that the Self becomes weak compared to three categories of parts: exiled parts holding scary, painful memories which can be triggered, manager parts which are vigilant for danger and keep the exiled parts exiled, and firefighter parts which react aggressively if apparent danger or an exile get too close.

As a model of therapy, IFS gently works with the Self of a client to calm and contain the manager and firefighter parts so that the exiled parts can be heard and healed.  When this happens, the Self naturally regains leadership of the intrapsychic system.

Sequences. The sequences metaframework is a way of looking for constraining patterns of behavior at different time increments.  Constraining patterns can exist at the level of individual interactions, such as conversations or arguments, at the level of daily routines, such as work or school schedules, at the level of longer cycles, such as yearly holiday rituals or seasonal production cycles, or at the level of intergenerational patterns, such as inheriting a tendency for abusing people or substances from parents or grandparents.  Breunlin and colleagues also acknowledge the possibility of longer cycles, such as Strauss and Howe’s (1991) four-generation cycle, or even larger societal shifts of values.  The different temporal levels of patterning also interact with each other recursively.  Patterns at any level can exacerbate or ameliorate patterns at any other level.

A metaframeworks-oriented therapist who suspected constraining sequences would choose interventions from models of therapy which specialize in the relevant temporal level of sequence.  Constraints at the level of face-to-face interactions, might best be resolved using techniques from the MRI school of thought, for example, while constraints at the level of intergenerational patterns might be best resolved using Bowenian interventions.  Or if a therapist suspects that one pattern is ameliorating a different, more constraining pattern, solution-focused interventions may be the most appropriate.

Organization. The organization metaframework is used to assess for constraints of balance, harmony, and leadership at various levels of organization.  Balance is a state in which each part of a system has an appropriate amount of resources and power compared to other parts. Harmony is the presence of cooperation and a balance between autonomy and interconnectedness between parts.  Some parts of a system appropriately provide leadership for that system, regulating the flow of resources, and planning for the future with the health of the whole system in mind.  Parents, for example, appropriately fill this role in nuclear families, and elected leaders in democratic societies.  Weak, rigid, or extreme leadership indicates constraints on a system’s organization.

A metaframeworks-oriented therapist who suspected organizational constraints might choose interventions from models of therapy which specialize in that kind of organizational constraint.  Structural, strategic, and Bowenian family therapies, for example, focus in different ways on the quality of boundaries and leadership in a system which can constrain harmony and balance.

Development. The development metaframework reminds us that there are more or less predictable developmental pathways that each level of organization follow.  It is important to keep the milestones of those paths in mind in order to recognize, normalize, and ameliorate constraints that can appear at each stage of each level: biological, individual, relational, and familial, recognizing a recursive relationship between developments at all levels, including societal.  Breunlin and colleagues use an adaptation of Carter and McGoldrick’s (1988) family life cycle theory for family development, an adaptation of Wynne’s (1988) relational development theory for relationships, and posit a theory of individual development in which people in a transition between more stable stages exhibit an oscillation between behaviors appropriate to the old and new stages.  In the absence of constraints, the oscillation dampens towards the new stage.  An oscillation of competence that is maintained is a clue to the presence of significant constraints.

A metaframeworks-oriented therapist should notice and resolve four types of developmental constraints, promoting synchronous development between all levels of organization:  First, if a family is not adapting flexibly to a new life-cycle stage, they are encouraged to notice and adapt to their new circumstances.  Second, if an individual is exhibiting behavioral oscillations, the therapist collaborates with the family to facilitate age-appropriate competence.  Third, in the presence of a biological constraint to development in an individual, the therapist encourages the family to adjust their expectations appropriately.  Fourth, therapists  help enhance any underdeveloped relationship qualities: attraction, liking, nurturing, coordinating meaning, rule setting, and metarules.

Multicultural. The multicultural metaframework is a perspective for therapists to use which takes into account the cultural diversity present in both our clients and ourselves, and the potential interactions between those cultures.  They include immigration status, economic status, education, ethnicity, religion, gender, age, race, minority/majority status, regional background, sexual orientation, disability, and the presence of marginalizing physical characteristics.

A metaframeworks-oriented therapist uses the multicultural metaframework to generate questions, conversations, and knowledge about how the therapist’s and clients’ diversity affect the experiences we have and the meanings we make of them.  The degree of cultural overlap, orfit, between client and therapist, majority and minority factions, or between immigrant and host cultures is a clue to the possibility of constraints; any area of cultural incongruity is likely to produce constraints on the part with less resources and control.

Gender. The gender metaframework is a systemic feminist perspective on therapy, based on the ideals of egalitarianism between genders and ecofeminism, a philosophy of interrelatedness and compassion between all.  Breunlin and colleagues propose a developmental scheme for gender in relationships from traditional, with patriarchal gender roles, to gender aware, where women begin to become angry and men fearful about power and gender roles, to polarized, where those angry and fearful parts are running the show, to balanced, where an egalitarian organization is idealized by both men and women, who work to achieve it.

A metaframeworks-oriented therapist uses the gender metaframework to highlight and attempt to release clients from the constraints of patriarchy.  The therapist identifies the gender stage a client and/or client system is at, and uses questions, statements, and directives designed to move the client or system toward the balanced, egalitarian stage.

The blueprint for therapy and the role of the therapist. A metaframeworks-oriented therapist aims to find and remove constraints that are holding clients back from flexible adaptation, balance, and harmony, keeping in mind that problems can be generated by a recursively interacting constellation of constraints existing at any level of organization, and in the form of any of the metaframeworks’ domains.  This means that therapy for each client will be unique, addressing their particular constellation.  That unique therapy is accomplished with four recursively interacting processes:  (a) Hypothesizing is taking an educated guess at what relevant constraints exist, taking care to remain curious rather than adamant about the truth of hypotheses.  (b) Planning is collaboratively implementing techniques and interventions from any model of family therapy that the current hypothesis suggests, taking care to tailor those interventions to fit the assumptions of metaframeworks.  Planning includes relating, or maintaining the therapeutic relationship, staging, or keeping an eye on the current position in the therapeutic arc, and creating events, which is the actual implementation of interventions.  (c) Conversing means conducting the therapeutic conversation, using questions, statements, and directives, taking care to use language that does not produce defensiveness or confusion in clients.  (d) Reading feedback is the process of recognizing and distinguishing the importance of what clients do and say, taking care to remember that clients are speaking and we are listening from the standpoint of personally and culturally limited perspectives.

A metaframeworks therapist relates to their clients under two balancing principles.  First, it is the therapist’s job to provide leadership for the process of therapy.  Second, for a true collaboration, the therapist must remain honest and clear about what they are doing, thinking, and why.  Under those principles, the therapist moves intuitively between the four components of therapy, hypothesizing, planning, conversing, and reading feedback, and between the six metaframeworks, mind/IFS, sequences, organization, development, culture, and gender.  Doing so, they are most likely to recognize the relevant constraints and deliver effective interventions in a respectful way.

Evidence and a Rationale for the Use of Metaframeworks

There appears to be very little experimental evidence to date supporting Breunlin and colleagues (1997) theory of therapy specifically.  A PsychInfo search on December 3, 2010 for “metaframeworks” produced, for example, only 15 relevant hits.  Two of those were editions of Breunlin and colleagues’ book (1992; 1997), 5 were theoretical chapters (Breunlin & Mac Kune-Karrer, 2002; Breunlin, Rampage, Eovaldi, Mikesell, 1995; Foy & Breunlin, 2001; Lebow, 2003; Rampage, 1998), 3 theoretical doctoral dissertations (Luther, 1995; Nehring, 1998; Schneider, 1998), 2 theoretical journal articles (Breunlin, 1999; Pinsof, 1992), 1 journal article about a metaframeworks training video (Cohen & Abed, 2003).and 1 book review ( Lawson, 1993).  The only hits purporting empirical evidence about metaframeworks (Oulvey, 2000) admits in the abstract that the research design invalidated any results.

A PsychInfo search for “internal family systems” did little better:  The approximately 20 relevant hits were overwhelmingly theoretical presentations or critiques.  The 3 empirical hits consisted only of case reports.  Two were of a successful treatment of a 17-year old female with bulimia (Schwartz, 1987; Schwartz & Grace, 1989), and the other of an African-American family with a young, female sexual abuse survivor (Wilkins, 2007).

Though this may not represent every piece of empirical evidence supporting the metaframeworks theory of therapy, it is clear that neither its tenets nor effectiveness have any strong empirical support.  While we cannot assert with any certainty what forthcoming evidence will suggest about metaframeworks, we can safely assume that the present dearth of evidence in either direction is a result of the newness of the theory rather than the bias of scientific journals against publishing null results.

A rationale for the use of metaframeworks at this point, therefore, must be primarily theoretical.   Theoretically, the efficacy of a therapist using metaframeworks is likely to fall within the same range as other models of therapy, since all models of therapy that have been tested so far appear to function in approximately the same range (Miller, Duncan & Hubble, 1997).  Why should metaframeworks be different?  There are optimistic and pessimistic views:

An optimist about metaframeworks might say that metaframeworks stands to outperform other models for two reasons. First, the stress in the diathesis-stress model is likely to exist in many different forms, and metaframeworks looks systematically at most of the forms we know about, where other models tend to focus on one or two.  Second, to the extent that the efficacy of therapy relies on model-specific techniques and interventions, famously estimated at 15% by Lambert (1994), metaframeworks can benefit from the techniques of every model of family therapy, plus multiculturalism, feminism, and psychodynamics.  Adopting those ideas from other models when appropriate will potentially benefit a metaframeworks-oriented therapist without falling prey to any specific model’s blind spots or other weaknesses.  Metaframeworks’ strength is the sum of the strengths of other models.

A pessimist about metaframeworks might argue that the complexity and sophistication of metaframeworks could stand in the way of success.  We still operate inside a 50-minute-per-week schedule, after all, and there’s only so much one can accomplish in that time.  Perhaps metaframeworks is just an extra-confusing and complicated way to provide the benefits of a therapeutic relationship.  If that is the case, metaframeworks may turn out to be somewhat less effective than other models of therapy.

At this point, there is not enough evidence to say who is right, or where on that optimist-to-pessimist spectrum “right” falls.  For the therapist who is a metaframeworks optimist, like myself, it is clearly important to know the model thoroughly, be able to negotiate its concepts and connections fluidly, and to be fluent with nearly all of the interventions of IFS and the other family therapy models.  Not to do so would be to fall prey to the critique of the pessimist.

Critique/Limitations

Though an optimist about metaframeworks, I believe I see weaknesses in the model. As a family therapist in training, all I can offer is a theoretical critique of the theory, and having just made contact with metaframeworks, my critique may be severely limited by my understanding, but it will show the extent of my understanding.

First, it is not clear to me how the IFS model is a true metaframework the way sequences, organization, and the others are, existing at every level of organization.  IFS seems to be primarily a model for working with individuals’ internal dynamics—almost more of a level than a metaframework.  How does a society-level constraint show up in the IFS framework, for example?  Also, once you admit that working with psychodynamics is useful, you will need to justify using a new model like IFS over a more mature model, of which there are many.  The idea of using systems thinking to approach psychodynamics is intriguing but somewhat less intuitive than systems thinking for families.

I have similar questions about the developmental metaframework.  While Breunlin and colleagues (1997) mention changing values at the level of societies, there is no attempt to put forth a developmental scheme.  Change is not development in the psychological sense.  There are society-level developmental schemes available, such as those put forth by Gebser or Graves (e.g. Graves, 1970; Wilber, 2000) which might be useful in creating a true developmental metaframework.  Development is also ignored on the community level, though I have no ideas on how to improve that.  The developmental scheme put forth for individuals, that of oscillation at developmental nodes, is simplistic compared to the wealth of knowledge developmental psychologists have discovered.  They make no mention even of the foundational work of Piaget, Kholberg, or Gilligan.

The gender metaframework has elements of cultural imperialism:  The therapist knows better than the clients and is duty-bound to change them, if possible.  I believe the problem lies in the gender-relations developmental scheme.  In the description of traditional to gender aware to polarized to balanced there is the clear judgment of very bad to less bad to even less bad to good.     While there is truth to this judgment, it limits the therapist, I think.  A better developmental scheme would, as an option, allow for and encourage a positive expression of traditional value-structure,s rather than a simple, negative judgment of the large majority of the earth’s cultures.

Finally, while metaframeworks seems to do an admirable job of integrating the good ideas from the original systems-oriented therapies, it provides no clear space for the good ideas from other therapy models.  I am specifically missing three elements.  First, Johnson’s twin breakthroughs of incorporating attachment theory and a focus on emotions in couples therapy (e.g. Johnson, 2004).  Second, the tools of cognitive therapy for examining meaning and resolving problematic meaning-making (e.g. Beck, 1979).  Third, mindfulness practices and interventions (e.g. Dimeff, Koerner, & Linehan, 2007).

 

Metaframeworks and Depression in Couples

As a metaframeworks-oriented therapist, when presented with a couple who complain of depression, I would assume that these are naturally resourceful people who are operating under some constraints right now.  It is likely that some number of factors in the web of possible constraints is providing the stresses that have triggered and maintained the symptoms of depression.  I would enter into a conversation with this couple, listening for clues as to what these constraints might be, at what level of organization, and seen clearest with the perspective of which metaframework.

It may be that one of those constraints is biological and at the individual level of organization—that is, a genetic tendency for depression—and that antidepressant medication or some other somatic intervention would be necessary.  If a thorough assessment for suicidality is negative, however, I would try out other hypotheses first, to see if releasing other constraints is adequate, as antidepressant medications have side effects while the releasing of other constraints does not (Breunlin et al., 1997).

I would take the couple’s lead in our conversation.  What do they think is important to talk about?  Chances are, they have some strong and useful ideas about where their stress is coming from, or at least when it is they feel the most stressed and when and where they feel the least stressed.  During the conversation I would keep the metaframeworks in mind, and the levels of organization, listening for clues about which hold the relevant constraints, which I would follow up on, developing and checking out hypotheses.

Do they complain about communication problems?  That would be a clue that the sequences metaframework may be involved at the interaction level.  If that checked out, it might suggest an interaction-oriented intervention, such as Gottman’s soft-startup psychoeducation, or one of Satir’s congruent-communication exercises.  I would also keep in mind the other levels of sequences.  Is there evidence for constraining daily routines?  Any chance of seasonal affective depression or holiday blues?  How about a history of depression in the family, a possible intergenerational sequence?  I would keep in mind that any sequences I come across can interact recursively with each other, generating, maintaining, regulating, or exacerbating each other.  I would hold my hypotheses lightly, listening for evidence against them, and when I felt like I had a good one, I would try an intervention, watching and listening for, and respecting, any feedback I got from the couple.  Whether or not the intervention brought out evidence for or against my hypothesis, I would use that evidence to generate new directions in the conversation, new questions, more accurate hypotheses.

I may come to suspect that internal family systems are involved in the depression, perhaps in the form of a polarization between angry and disappointed parts of each partner, or between perfectionist and overwhelmed parts of one of the partners.  If that seemed like the case, I could try working with the parts, calming the extreme parts and encouraging the leadership of the Self.  Throughout the process, I would keep in mind that both the levels of organization and the metaframeworks interact recursively.  Are these parts reflected in an intergenerational sequence?  A family-level organization pattern? How about a society-level pattern?  I would follow up on any relevant-seeming clues, getting feedback from the couple, developing a richer understanding of their situation.

I would keep an eye out for organizational and developmental constraints.  Does the couple lead their family appropriately?  Are there parentified children? Cross-generational coalitions?  These might begin to suggest structural or strategic interventions, modified for maximum respectfulness, of course.  Are they at a nodal point in the family life cycle? Having their first child? Launching their last child?  Is there evidence of an oscillation in competence?  To what stage has their relationship developed?

I would investigate and keep in mind the couple’s multicultural and gender aspects, watching for friction from a poor cultural fit, or gender-based power dynamics.  Is either partner an immigrant?  Second- or third-generation American?  Is their socioeconomic class a fit with each other, or suffer from the constraints of poverty?  What is their sexual orientation and what other ways do they identify with majority or minority cultures?  How do they think about religion?  Education?  How about gender?  Have they taken on traditional gender roles or have they begun to chafe under them?  Achieved balance?  How might I support the partner who has less power to stand up for themself?  How might I support the partner with more power to more gently move through the transition to gender balance?

Culture and gender are also where I would keep a close eye on myself:  How might my culture and gender be constraining my thinking or compassion with this couple?  How might our similarities or differences blind me to possible constraints?  I would quite possibly check in with a colleague or supervisor about this.

Ideally, I would move our conversation with purpose and fluidity through, and back and forth between, the different metaframeworks and the different levels of organization, identifying and releasing constraints by staging and creating events and reading the feedback.  If the depression was the result of just a few constraints, the process might be fairly simple.  If the depression was the result of a dense, heavily embedded constellation of constraints, the process might take longer and involve many iterations of rethinking, shifting hypotheses, trying out different angles and interventions.  Ideally the process would also be intuitive, so that I could just follow my natural curiosity and the natural flow of our conversation.  And, ideally, as a result of our conversation, the other events, like interventions, we orchestrate in our relationship, and the quality of our relationship, the constraints release and the couple finds that they no longer struggle with depression.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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Appendix

Mind Sequence Organization Development Culture Gender
Society
Community
Family
Relationship
Person
Biology

Figure 1. The levels of organization as conceptualized by Breunlin, Schwartz, and Mac Kune-Karrer (1997) are on the vertical axis and the metaframeworks are on the horizontal axis.

Bertalanfy, Intelligent Design, and the 2nd Law of Thermodynamics

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I posted this on my Advanced Family Theory discussion board a couple weeks ago. There were no replies:

According to Metaframeworks (p. 30) (which I’m loving, by the way), one of the ways which Bertalanffy distinguished organic from mechanical systems is that organic systems violate Newton’s 2nd law of thermodynamics. That is, we and the larger systems we are part of grow increasingly complex, even though Newton predicted only increasing disorder according to the rules of thermodynamics.

This “evidence of negentropy” is one of the major planks of the “intelligent design” argument for a creator being logically deducible by the presence of organic systems. Unfortunately for ID-ers and Bertalanffy, life does not violate Newton’s 2nd law because even though organisms and other phenotypes are highly and increasingly complex, our living and doing create disorder much more efficiently than nonliving systems. That is, it’s more accurate to say that Newton’s 2nd law drives the complexity of life than to say that life violates that law.

If you are as excited as I am by this idea, check out Dorion Sagan’s Into the Cool: Flow, Thermodynamics, and Life.

[First published on Nathen’s Miraculous Escape, as “A Very Nerdy Note about Bertalanfy and the 2nd Law of Thermodynamics,” on November 21, 2010.]

Some Views on the Nature of Reality

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In the field of family therapy, most theorists these days are postmodern and take care to spell out their epistemological lens–how and why they think they know what they know. They know that their theories are colored by their beliefs, so they want their readers to know what biases were involved in creating their theory.

I’m on page 33 of a very promising family-therapy-theory book called Metaframeworks: Transcending the Models of Family Therapy. The authors describe four views of reality, how they relate to each other, and which one they choose. The four are:

Objectivism: The often unconscious belief that there is an objective reality and that we have direct access to it. This view is also called “naive realism.”

Constructivism: This camp generally believe that a reality exists out there independent of us, but that we can’t know what it is like because our access to it is completely mediated and limited by our senses and cognitive processes. This is also called “pessimistic realism.”

Perspectivism: There is a reality out there and we have only mediated, distorted access to it, but it is possible to map it to greater and greater degrees of accuracy. That is, some maps are better than others. This is the authors’ camp.

Radical Constructivism: As far as we know, “reality” exists only in the mind. We are not qualified to make any statements about what actually exists or goes on “out there.”

[First published on Nathen’s Miraculous Escape, November 19, 2010.]

Whitaker on “Social Therapy”

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I’m reading Whitaker and Malone’s 1951 book The Roots of Psychotherapy, an early attempt at a general theory of therapy. Whitaker was a psychiatrist who started working with families in the very early days of the family therapy field. It’s a good book, though not an easy read.

My favorite of his ideas so far is that of the social therapist. He says that since everyone has troubles, and everyone has some capacity to help others through troubles, everyone is a potential “patient” (therapists still called their clients “patients” back then), everyone is a potential “social therapist,” and every interaction between people has the potential to be therapeutic.

What causes a potential “patient” to become an actual “patient,” and go ask a professional therapist for help is a failure of that person’s social-therapy community to help with their troubles. That, and the “patient’s” overcoming their own fear of change and their fear of the stigma our culture places on getting therapy.

Whitaker also tackles the sticky question, “What is a cured patient?” and concludes, “In short, the patient gets access to other human beings and, incidentally, enters the community as an adequate social therapist, no longer so concerned with himself that he cannot get and give therapy to others in a social setting.” (p. 79)

[First published on Nathen’s Miraculous Escape, October 30, 2010.]

Five Fears About Emotions

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I’m studying Emotionally Focused Couples Therapy, or EFT, this term in my Couples and Family Therapy master’s program. In her book for therapists, Susan Johnson writes that many people, especially those with histories of trauma, have strong fears about expressing strong emotions. She gives five common examples. These are directly quoted from her book, Emotionally Focused Couples Therapy, p. 73:

We may fear that if emotions are unleashed, they will go on forever.

We may fear that we will be taken over by such emotions and our ability to organize our experience, our very sense of self, will disappear.

We fear that we will lose control and be slaves to the impulses inherent in these emotions, and so we may make things worse or actively harm ourselves or others.

We fear we will not be able to tolerate these emotions and will go “crazy.”

We fear that if we express certain emotions, others will see us as strange and/or unacceptable.

[First published on Nathen’s Miraculous Escape, October 22, 2010.]

Diagnostic Criteria for Substance Abuse and Dependence

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I’m taking a class called Contemporary Issues in Addiction. One of the things we’re learning about is how different clinicians think about addiction. Here are the official diagnostic criteria for substance abuse and dependence, word-for-word from the DSM-IV-TR:

Criteria for Substance Abuse

A. A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by one (or more) of the following, occurring within a 12-month period:

(1) recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home (e.g., repeated absences or poor work performance related to substance use; substance-related absences, suspensions, or expulsions from school; neglect of children or household)

(2) recurrent substance use in situations in which it is physically hazardous (e.g., driving an automobile or operating a machine when impaired by substance use)

(3) recurrent substance-related legal problems (e.g., arrests for substance-related disorderly conduct)

(4) continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance (e.g., arguments with spouse about consequences of intoxication, physical fights)

B. The symptoms have never met the criteria for Substance Dependence for this class of substance.

Criteria for Substance Dependence

A maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring at any time in the same 12-month period:

(1) tolerance, as defined by either of the following:

(a) a need for markedly increased amounts of the substance to achieve intoxication or desired effect

(b) markedly diminished effect with continued use of the same amount of the substance

(2) withdrawal, as manifested by either of the following:

(a) the characteristic withdrawal syndrome for the substance (refer to Criteria A and B of the criteria sets for Withdrawal from the specific substances)

(b) the same (or a closely related substance is taken to relieve or avoid withdrawal symptoms

(3) the substance is often taken in larger amounts or over a longer period than was intended

(4) there is a persistent desire or unsuccessful efforts to cut down or control substance use

(5) a great deal of time is spent in activities necessary to obtain the substance (e.g., visiting multiple doctors or driving long distances), use the substance (e.g., chain-smoking), or recover from its effects

(6) important social, occupational, or recreational activities are given up or reduced because of substance use

(7) the substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance (e.g., current cocaine use despite recognition of cocaine-induced depression, or continued drinking despite recognition that an ulcer was made worse by alcohol consumption)

Specify if:

With Physiological Dependence: evidence of tolerance of withdrawal (i.e., either Item 1 or 2 is present)

Without Physiological Dependence: no evidence of tolerance or withdrawal (i.e., neither Item 1 nor 2 is present)

Course specifiers (see text [below] for definitions)

Early Full Remission

Early Partial Remission

Sustained Full Remission

Sustained Partial Remission

On Agonist Therapy

In a Controlled Environment

Here are those definitions, from pp. 196-7:

Early Full Remission. This specifier is used it, for at least 1 month, but for less than 12 months, no criteria for Dependence or Abuse have been met.

Early Partial Remission. This specifier is used it, for at least 1 month, but less than 12 months, one or more criteria for Dependence or Abuse have been met (but the full criteria for Dependence have not been met).

Sustained Full Remission. This specifier is used if none of the criteria for Dependence of Abuse have been met at any time during a period of 12 months or longer.

Sustained Partial Remission. This specifier is used if full criteria for Dependence have not been met for a period of 12 months or longer; however, one or more criteria for Dependence or Abuse have been met.

On Agonist Therapy. This specifier is used if the individual is on a prescribed agonist medication such as methadone and no criteria for Dependence or Abuse have been met for that class of medication for at least the past month (except tolerance to, or withdrawal from, the agonist). This category also applies to those being treated for Dependence using a partial agonist or an agonist/antagonist.

In a Controlled Environment. This specifier is used if the individual is in an environment where access to alcohol and controlled substances is restricted, and no criteria for Dependence or Abuse have been met for at least the past month. Examples of these environments are closely supervised and substance-free jails, therapeutic communities, or locked hospital units.

[Post first published on Nathen’s Miraculous Escape, October 4, 2010.]

“Gaming”

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This quote came after a shocking first-person description of what it’s like to work at a casino, mostly ripping off the Social Security and pensions of elderly folks with gambling problems:

“In this politically correct decade, the most horrific politically correct term ever created is the one that the gambling industry has made into an everyday word: Gaming. There is no game here. You pay and you lose; that is the game.”

–Addiction Treatment, Van Wormer & Davis, p. 7

[First published on Nathen’s Miraculous Escape, October 20, 2010.]

Diagnostic Criteria for Gender Identity Disorder

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The existence of Gender Identity Disorder as an official mental disorder is troubling to the trans folks I know. They think of their condition they way most people now think about homosexuality: It’s just another normal way to be a human being that makes people who don’t understand it so afraid that they’ve called it a disorder. Some people are just born into bodies that don’t match their psychological gender.

There are other problems. There is the DSM’s requirement to specify whether the diagnosed individual is attracted to males, females, both, or neither. If homosexuality is not a mental disorder, why should it matter clinically what genders a transsexual is attracted to? Then there’s the fact that GID is in the DSM right next to the sexual disorders like sexual sadism, masochism, and pedophilia. What is the connection?

So in a way, it would be great to get GID removed from the DSM, like homosexuality was in the 1970s. Unfortunately, if GID were not an official mental disorder, insurance companies wouldn’t pay for the expensive surgeries and hormone treatments involved in transitioning. According to my friends, living in a body of the wrong sex is so painful and humiliating that many pre-operation trans folks kill themselves, while suicide is rare for those who do who get the operations. So if you are poor and trans, your life may depend on GID being an official mental disorder.

There may be some changes coming to the diagnosis (see here) in the upcoming DSM-V, and my friends are saying they sound somewhat better. Here’s how they stand right now, in theDiagnostic and Statistical Manual of Mental Disorders IV-TR:

Diagnostic criteria for Gender Identity Disorder

A. A strong and persistent cross-gender identification (not merely a desire for any perceived cultural advantages of being the other sex).

In children, the disturbance is manifested by four (or more) of the following:

(1) repeatedly stated desire to be, or insistence that he or she is, the other sex

(2) in boys, preference for cross-dressing or simulating female attire; in girls, insistence on wearing only stereotypical masculine clothing

(3) strong and persistent preferences for cross-sex roles in make-believe play or persistent fantasies of being the other sex

(4) intense desire to participate in the stereotypical games and pastimes of the other sex

(5) strong preference for playmates of the other sex

In adolescents and adults, the disturbance is manifested by symptoms such as a stated desire to be the other sex, frequent passing as the other sex, desire to live or be treated as the other sex, or the conviction that he or she has the typical feelings and reactions of the other sex.

B. Persistent discomfort with his or her sex or sense of inappropriateness in the gender role of that sex.

In children, the disturbance is manifested by any of the following: in boys, assertion that his penis or testes are disgusting or will disappear or assertion that it would be better not to have a penis, or aversion toward rough-and-tumble play and rejection of male  stereotypical toys, haves, and activities; in girls, rejection of urinating in a sitting position, assertion that she has or will grow a penis, or assertion that she does not want to grow breasts or menstruate, or marked aversion toward normative feminine clothing.

In adolescents and adults, the disturbance is manifested by symptoms such as preoccupation with getting rid of primary and secondary sex characteristics (e.g., request for hormones, surgery, or other procedures to physically alter sexual characteristics to simulate the other sex) or belief that he or she was born the wrong sex.

C. The disturbance is not concurrent with a physical intersex condition.

D. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Code based on current age:

302.6     Gender Identity Disorder in Children

302.85   Gender Identity Disorder in Adolescents or Adults

Specify if (for sexually mature individuals):

Sexually Attracted to Males

Sexually Attracted to Females

Sexually Attracted to Both

Sexually Attracted to Neither

[First posted on Nathen’s Miraculous Escape, August 22, 2010.]

Something to Know About Stonewallers

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When your partner in a relationship stonewalls, what does it look like? They might leave the room or house. They may stop talking and ignore you. If they are an accomplished stonewaller, they probably look like they don’t care, are calm and unaffected. They look like “You could stand there screaming all day and I wouldn’t bat an eyelash.”

The first thing to know about this behavior is that, if it happens very often, your relationship is likely in trouble. You probably needed couples counseling years ago.

That is pretty common knowledge these days, now that John Gottman’s work is so well known. What I found surprising about stonewallers when I read his work is that if you hook a stonewaller up to a biofeedback machine like a heart-rate monitor, you find out that they are freaking out inside. Their heart rate and blood pressure are way up. They just look calm or withdrawn. They are actually so painfully engaged that they can’t deal with it. This knowledge has helped me think more clearly about stonewallers. I can be a lot more sympathetic to someone I know to be in something like flight-fight-freeze mode than someone who appears to be shutting me out.

[First published on Nathen’s Miraculous Escape, July 21, 2010.]