5. Marriage is About DepAnxiety! - RonaldMah

Ronald Mah, M.A., Ph.D.
Licensed Marriage & Family Therapist,
Consultant/Trainer/Author
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I Don't… You Don't… It Don't Matter, Depression and Anxiety in Couples and Couple Therapy
Chapter 5: MARRIAGE IS ABOUT DEPRESSION AND ANXIETY!


"There is ample evidence that depressed persons experience hostile and conflicted relations with their spouses, children, and other social network members (Gotlib & Whiffen, 1991)" (Wiffen et al., 2001, page 577).  The therapist should examine the interplay "between intrapsychic vulnerabilities and interpersonal contexts."  Self-esteem comes from the attention and care of others- primarily initial caregivers and subsequently, other intimate others.  Mattering to others and having power and control relative to life and relationships affects anxiety and depression.  Stimpson et al. cited multiple references to marriage as a major social context.  "One of the most important social contexts may be marriage because this interdependent relationship provides an important source of social support, identity, and satisfaction (Stack & Eshleman, 1998).  The positive connection between marriage and health has been well documented (Mirowsky & Ross, 2003; Waite, 1995).  Marriage is associated with lower mortality rates (Smith & Zick, 1994; Tower, Kasl, & Darefsky, 2002), better physical health (Robles & Kiecolt-Glaser, 2003), and better psychological well-being (Barrett, 2000).  The protective effect of marriage may be particularly important to older minority couples as they lose social ties and their physical health deteriorates in their later years (Carstensen, 1992; Cutrona, 1996)" (Stimpson et al., 2005, page 386).  Stress is an inherent part of life and often abounds in the challenges of life's most fulfilling elective and selective relationship- marriage or the committed intimate romantic relationship.  "The emotional manifestation of stress is characterized by anxiety and depression (Lazarus, 1993; Lovibond & Lovibond, 1995).  A demonstrated clinical overlap exists between anxiety and depression (Akiskal, 1985; Clark, 1989; Dobson, 1985; Stavrakaki & Vargo, 1986). Thus, measures of both anxiety (Derogatis, 1982; McLean, 1976) are used in research as indicational manifestations of stress.  Coping with stress, in terms of Lazurus and Folkman's (1984) transactional model, refers to the continuous cognitive and behavioral attempts the individual makes to manage the demands of a situation that he or she perceives as taxing (or stressful)" (Spangenberg and Theron, 1999, page 254).

Any close and healthy relationship has the potential to mitigate difficult and problematic circumstances.  By the same token, any conflictual, disempowering, invalidating, or hurtful relationship is likely to exacerbate life challenges- perhaps, making them intolerable.  Harper and Sandberg (2009) examined research about the influence of marital satisfaction on older couples' experiences with a number of very challenging circumstances.  Marital satisfaction lessened the link between negative marital processes and depression for older couples.  The quality of marital satisfaction was strongly related to depressed affect for older couples.  "In their article, Bookwala and Franks (2005, page 547) attempted to move beyond main effect research that has shown a direct link between marital quality and depression for couples across the life span.  In addition to supporting the main effect in older marriages, these authors also found that 'respondents with physical disability who were in marriages marked by higher marital disagreement reported significantly greater depressed affect than elders with similar levels of physical disability who were in less conflictual marriages' (p.340)."  Despite the trials of age and physical disabilities, older individuals who are able to find needed closeness in marriage were less likely to be depressed.  Partners' levels of depression influence depression in each other.  "In fact, it may be the couple's ability to interact in positive ways during health and other crises that can help to moderate the effects of depressive risk factors (Sandberg & Harper, 1999, 2000a, 2000b; Sandberg, Miller, & Harper, 2002; Tower & Kasl, 1996a)" (Harper and Sandberg, 2009, page 547).  The couple of any age may come to therapy seeking aid in eliminating the problems and challenges in their relationship and in life.  These issues however are often be part and parcel of life and an intimate relationship.  The lesson from older couples may be that all difficulties are better met in by skillful partners in healthy emotionally fulfilling relationships. Therapy then becomes about increasing the couple's ability to interact positively: supportively and effectively in crises, including the daily crises of managing depression and anxiety.

Individuals tend to use habitual coping strategies to respond despite different stress demands.  Coping strategies can be broken into three types: problem solving, social support seeking, and avoidance.  These coping strategies strongly affect a person's well-being in many ways when stress challenges their functioning.  Stress can manifest in marriage or the intimate committed relationship as depression, anxiety, or both emotions.  The partner of a depressed person may be required to take on additional responsibilities including managing money and expenditures and children's care and activities.  Such new responsibilities may become stressful and contribute to depression developing in the previously emotionally sound partner.  The partner of a depressed person may also feel frustrated, consciously or unconsciously resentful and angry with the depressed partner, and a sense of being unfairly overburdened.  Social activities and interactions with others can be hindered by the depression, leading to a sense of being restricted and isolated for the non-depressed partner.  This can place further stress on and create damage to the relationship.  "Effective coping by the spouse of a depressed patient can prevent the development or resumption of marital conflict and thus prevent marital conflict from aggravating the depression.  In addition, it can aid the patient's recovery (Krantz & Moos, 1987).  At the same time, effective coping can prevent or at least limit the development of depressive symptoms in the healthy spouse (Hinrichsen, 1991)" (Spangenberg and Theron, 1999, page 254).  Since stress is inherently a part of the experience of having a deeply depressed partner, "The high anxiety levels experienced by the spouses most probably hamper their ability to give emotional and practical support to their depressed partners.  Poor emotional support from the spouse can, in turn, play an important role in aggravating depression in the depressed patient (Brown & Harris, 1978) (Spangenberg and Theron, 1999, page 259).  Both partners become vulnerable to anxiety, depression, and health problems in relationships with a depressed partner.

The therapist should examine not only for key issues that trigger stress, but also the various coping strategies of each partner and the couple for effectiveness and efficiency.  In some couples, the stress is not so much the major issue, but the poor coping strategies and skills that leave one or both partners unfulfilled, feeling dismissed, and/or uncertain not only about resolutions, but about the care and investment of the other partner in oneself.  "In marriage, for example, the wife may perceive that the husband is spending too much time away from home. As a result, she may feel sad or hurt.  Although the expression of these negative emotions could lead to conflict, it could also result in increased understanding between partners and it could motivate the husband to spend more time at home.  In this way, the expression of negative emotion may ultimately facilitate interactive coping (Barbee, Rowatt, & Cunningham, 1998) and increase relationship closeness and satisfaction.  Thus, in interpersonal relationships between adults, the experience and appropriate expression of some negative emotions should be beneficial for relationship functioning (Sanford and Rowatt, 2004, page 329).  The key to whether expression of sadness or other negative emotions may be beneficial to the relationship has to do with both their expression appropriately and the response of the partner appropriately.  Expressing sadness in response to negative behavior by the partner tends to lead to more beneficial relationship results than expressing anger.  Being able to be sad and express it in the relationship facilitates intimacy when there is conflict between partners.  An individual's expression of sadness as opposed to anger is more apt to elicit compassion and understanding from a partner.  Sad feelings may help reduce arousal and suppress attacking or fighting instincts that would otherwise exacerbate conflict (Sanford and Rowatt, 2004, page 329-30).  Sadness is a soft emotion that elicits empathy and facilitates intimacy.  The emotion of hurt may also be productive in relationships because it "reflects a core concern for maintaining an interpersonal relationship, and it motivates a person to protect his or her relationship.  Thus, hurt and other similar soft emotions may play an important role in adaptive relationship functioning.  Accordingly, Johnson and Greenberg (1988) found that distressed couples receiving couples' therapy were most likely to improve when they experienced a softening during therapy, i.e., a shift from expressing hard emotion to showing vulnerability" (Sanford and Rowatt, 2004, page 330).  The therapist often seeks to get partners to be vulnerable and express "soft emotions."

Zavier and Aaliyah were describing a fight about money they had last week.  Each took a turn describing what "really" happened.  Both partners were agitated and upset ostensively at the other's actions and receiving unjustified anger.  After the two went a couple of rounds of accusing each other of being selfish and rude, as well as setting the "facts" straight to the therapist (as if the therapist cared about the "facts!"), the therapist asked, "In one short sentence, tell what really bothered you?"  Zavier said he didn't like Aaliyah giving money to her sister without asking him.  Aaliyah said she didn't like Zavier being insulting about her sister.  Both still had anger in their voices, faces, and body language.  Then the therapist asked, "What did you feel when Zavier said that?  What did you feel when Aaliyah said that?"  Both responded more or less that it made them mad.  The therapist said, "Usually, being mad… getting angry is a secondary emotion.  It's an empowering emotion that helps you take care of… helps you fight for yourself…  Anger is usually a secondary emotion to a primary vulnerable emotion that needs to be taken care of.  What was that vulnerable feeling?"

The therapist, sensing Zavier was more apt to reveal his feelings, asked him first, " Zavier, what was that vulnerable feeling you had when Aaliyah said that?"  Zavier responded in a quieter tone- in fact, his facial expression softened and his body language relaxed.  "I felt irrelevant.  We had talked about budgeting… and about being more careful.  And then Aaliyah ignored it..."  The therapist interrupted to steer him away from another accusation against Aaliyah, and focused him by asking, "What did you feel?"  Zavier said, "I felt kinda hurt… like what we talked about didn't matter… that I said and felt didn't matter."  The therapist interjected, "Like you didn't matter?"  "Yeah," said Zavier sadly, "like I didn't matter."  The therapist said in a firm but gentle tone, "That can't feel too good."  The therapist turned to Aaliyah, "Was that what you were doing… saying?  That what Zavier said or felt didn't matter… that he didn't matter?"  Aaliyah's facial expression and body posture had shifted from tension to a softer visage when Zavier had said he was hurt.  "No," she answered, "I wasn't trying to ignore him.  I care about him.  I just was trying…"  Again, the therapist interrupted to prevent the discussion from going back to accusations, excuses, and explanations that would be provoking or at best, unproductive.  "You weren't blowing him off.  You didn't want to disrespect him," said the therapist, thus reframing her response with the clarifying concept of "respect."

Zavier had gone first to his vulnerable feelings and risked putting them out to the therapist… while knowing that Aaliyah was also there.  Because he had been able to speak from simple emotions, Aaliyah was that much more able to also be vulnerable when the therapist proceeded to ask her what she felt.  When one or both partners are reluctant or unable to express "soft emotions," it is often a clear indication of the difficulty between the partners and a prediction of a more complex therapeutic process to come.  Not all partners or couples will or can respond as readily as Zavier and Aaliyah to the therapist's request to express vulnerabilities.  Soft emotions are related to high relationship satisfaction, low conflict, and low relationship avoidance.  They reveal weakness or vulnerability, and motivate one to seek comfort, support, or assistance from others.  Showing vulnerability involves trust in the other person, who if he or she responds appropriately increases intimacy and relationship satisfaction.  "As such, soft emotion may facilitate a non-avoidant, secure attachment bond in which the person enjoys closeness with the partner and is comfortable relying on the partner for support.  During conflict, soft emotion may suppress the motivation to use self-protective behavior and instead elicit empathy and support from the partner, thereby decreasing overall levels of conflict in a relationship" (Sanford and Rowatt, 2004, page 332).  When individuals in therapy or in the couple have difficulty expressing soft emotions, the difficulty can be seen as a diagnostic indicator of deeper issues that preclude what should and would be productive emotional expression and positive reception and response.

Sanford and Rowatt addressed hard emotion (anger) and fear-based emotion in addition to soft emotions.  Fear-based emotion is related to relationship anxiety.  Fear-based emotion can motivate behavior for self-protection against a possible partner attack or abandonment.  Zavier and Aaliyah had been expressing both hard emotion and fear-based emotion when initially talking about their fight.  If they had stayed or gotten stuck with such emotions, the interaction and potentially, the relationship would have deteriorated.  While fear-based emotion anticipates further hurt and rejection, it also can motivate seeking partner support and comfort.  Although not conscious of it, Zavier and Aaliyah were simultaneously seeking acknowledgement and nurturing from each other.  The therapist tried to bring that process out in the open, as well as facilitating nurturing responses.  Fear-based emotion is associated with relationship anxiety, when the desire for a close relationship is combined with fear of rejection or abandonment in the same relationship.  Torn between protecting oneself but still seeking intimacy, a partner may engage in contradictory behaviors-  "…behaviors that facilitate intimacy, empathy, and positive communication in a relationship and to engage in other self-protective behaviors that have the opposite effect… Relationship anxiety involves both desire for intimacy and worry about abandonment; yet soft emotion would not lead a person to worry about abandonment, and hard emotion would not lead a person to desire intimacy.  In summary, it is expected that hard and soft emotion will be related to relationship satisfaction, conflict, and relationship avoidance.  In contrast, fear-based emotion is expected to be associated with relationship anxiety" (Sanford and Rowatt, 2004, page 331-32).

Fear-based emotion or anxiety can be productive or harmful to a couple.  Self-protective behaviors may create appropriate boundaries and distance, avoiding enmeshment and maintaining individuality.  Thus, they can productive much like soft emotions- expressing vulnerability and deepen intimacy between partners.  "Accordingly, Johnson and Denton (2002) list both fear and anxiety as examples of vulnerable emotions that are likely to have a positive effect in a relationship.  Taken together, fear-based emotion may have an inconsistent effect on relationship satisfaction, yet it may be unique from other types of emotion in that it heightens relationship anxiety" (Sanford and Rowatt, 2004, page 351).  The therapist may attempt to soothe an individual's anxiety about the relationship, his or her partner's commitment and love to him or her, and other relationship insecurities.  However, the relationship may be served if the therapist purposely evokes deeper and unarticulated anxieties about potential rejection or abandonment for the partners to address directly.  The therapist got Zavier first, and later Aaliyah to express such deeper anxieties about losing the other person.  In some cases, current anxieties and hence current behaviors may be extensions or variations of older self-protective or intimacy seeking behaviors and experiences.  These may be from the family-of-origin and prior intimate romantic relationships.  In such situations, the anxiety or fear is that "it" (abandonment or rejection) will happen again.  Addressing such older abandonment and rejection fears proved relevant for both Zavier and Aaliyah and was dealt with concurrently with current problem solving.

The "cognitive–behavioral theory of marital functioning, as outlined by Baucom and Epstein (1990), identified anxiety specifically as one of four negative emotions believed to play an important role in marital distress.  They suggested that not only can anxiety disrupt marital functioning, but poor marital functioning may elicit symptoms of anxiety... McLeod (1994) examined marital quality in couples in which neither, one, or both spouses were diagnosed with an anxiety disorder.  Couples with at least one spouse meeting criteria for panic disorder, phobia, or generalized anxiety disorder tended to report lower levels of marital quality" (Dehle and Weiss, 2002, page 329).  Anxiety can affect the interpretation and processing of ordinary occurrences and ones partner's behaviors in ways that harm feelings.  Otherwise innocent behaviors may be seen as negative when a partner's anxiety lead to hypervigilance or hypersensitivity.  Negative interpretations make it more likely that the partner choose a negative response, which corrupts the quality of their interaction.  The initial approach would be to create a "predictive relationship between state anxiety and change in marital quality over time" (Dehle and Weiss, 2002, page 329).  The therapist can have the partners examine in great detail the process of their interactions and communications.  The linkages between anxiety and anticipation of negative treatment with ones perception of the other's communication and behaviors need to be established.  Further connections need to be made between negative perception and responses to the other's experience of the unexpected negativity, and then to his or her negative response.  

The therapist should try to get partners such as Zavier and Aaliyah to become aware of how anxiety-provoked choices create a self-confirming prediction of rejection or abandonment.  And how that affects their devolving experience of the relationship.  Each partner is affected by his or her feeling of anxiety and its connection to the quality of the relationship, while also affected by his or her partner's feeling of anxiety and its connection to the quality of the relationship.  "Thus, a spouse's anxiety may influence his or her own self-report of marital quality, and it may also influence the partner's judgment of marital quality through some mediating variable" (Dehle and Weiss, 2002, page 330).  Uncovering the previous and ongoing mutual and cyclical actions and reactions including those prompted by anxiety (anticipated rejection and abandonment) leads to the possibility of interrupting a process of relationship deterioration.  Various therapeutic orientations may serve to interrupt anxiety's role in either a disorder and the relationship.  Monson, et al. (2004), for example feel that Cognitive–Behavioral Couple's Treatment (CBCT) has been shown to be as effective as "individual psychotherapy in treating several disorders (i.e., depression, panic disorder/agoraphobia, substance abuse), with additional benefits of improved relationship satisfaction, parenting, and treatment delivery (e.g., cost savings, efficiency, less attrition), and reduced relapse and physical aggression (e.g., Daiuto, Baucom, Epstein, & Dutton, 1998; Jacobson, Dobson, Fruzzetti, Schmaling, & Salusky, 1991; O'Farrell & Fals-Stewart, 2000)."  They believe that PTSD interacts with the couple's behaviors and belief systems causing a reciprocal maintenance between relationship discord and PTSD symptoms.  As a result, behavioral and cognitive interventions directed at the couple, at the same time improve PTSD symptoms and relationship discord (page 341).

ADDRESS:
433 Estudillo Ave., #305
San Leandro, CA 94577-4915
Ronald Mah, M.A., Ph.D.
Licensed Marriage & Family Therapist, MFT32136
CONTACT INFORMATION:
office: (510) 582-5788
fax: (510) 889-6553
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