5. Psychoeducation Foundations - RonaldMah

Ronald Mah, M.A., Ph.D.
Licensed Marriage & Family Therapist,
Consultant/Trainer/Author
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Opening the Can of Worms, Complications in Couples and Couple Therapy
Chapter 5: PSYCHOEDUCATION FOUNDATIONS TO TREATMENT
by Ronald Mah





In a highly chaotic couple, the initial goal of therapy may need to focus on management rather than fundamental change or cure.  Managing the emotional reactivity in the session and managing it at home may be ongoing goals.  Without a stable forum in therapy or at home, issues cannot be worked through and problems negotiated.  Hyde (2001) addresses management issues when working with a bipolar client in the family,  "Management requires a change of perspective giving strong attention to psycho-education and behavioral intervention skills.  Therefore an important aspect of treatment is the tracking or mapping the course of an illness so that the family and the patient learn what to expect" (page 113).  Huxley et al (2000) identify five objectives in psychosocial treatments for bipolar disorder patients.  While they note that such treatments normally focus on improving medication compliance, the objectives specifically serve reducing the high negative emotion that is expressed with episodes of bipolar disorder behavior.

Educating the patient and sometimes his or her family about the illness and its treatment
Enhancing acceptance of illness
Improving monitoring of changes in mood and sleep and vigilance for other warning signs of impending recurrence
Establishing skills for limiting and coping with stress
Identifying the interpersonal difficulties commonly arising from being ill, and refining skills for managing them
Deriving support and encouragement from sharing experiences with other patients
Managing adverse experiences with long-term pharmacological treatment (page 127).

In a couple, when there is a bipolar partner who is not stabilized, the therapist must do psychoeducation about the course of mania and depression cycles.  Failure to understand and therefore, predict the challenged person's process complicates how others perceive him or her.  "The psychoeducational approach recognizes that lack of information about the disorder, along with uncertainties about the future, fuel patients' denial of the diagnosis and contribute to caregivers' high-EE attitudes" (Miklowitz, 2007, page 194).  Couples without a bipolar partner may be similarly unstable due to the emotional reactivity caused by some emotional or psychological challenge or characterological disorder.  The therapist can assert that while it may be difficult or immediately impossible to eliminate the negative behavior, the individual and the couple can come to understand and predict it better.  While the challenged individual may not be able to change quickly, the couple can change how it responds to and deals with the individual and his or her challenging behaviors.  This orientation focuses the individual and couple on the choices available as opposed to what cannot yet be done.  Management, a primary goal or boundary of stabilization for the individual's must often preclude any work to address couple's dynamics per se.  Bipolar individuals, however similar to addicts often need to crash and burn several times in order to "prove" to themselves that they really need to maintain a program or process to avoid mania.  Similarly, someone who suffers from PTSD based flashbacks or becomes emotionally reactive due to a personality disorder may also deny a need to change behavior.  They may need to endure periodic or frequent failures- crash and burn relationships for example, before accepting that they are not sufficiently functional.

The denial process and the prerequisite repetition of relationship failures may be particularly relevant to individuals with a personality disorder because their feeling and thinking processes are egosyntonic.  They do not always experience intrapsychic dissonance in their process.  Only when interpersonal relationships- romantic, peer, or vocational break down in a distressing life-long and enduring pattern may such an individual consider that his/her process is a problem.  If the bipolar or otherwise challenged individual is still in this proving/denial process despite harm to the relationship, the therapist should still offer education about his or her process.  Unable to stop the denial, the other partner and therapist can make choices about how to respond to the denial.  The therapist may use prediction, for example as a paradoxical intervention that the individual will persist until he/she experiences enough bad consequences (including losing the relationship) to learn the imbalance's reality.  For many individuals, the therapist can elicit a history of broken relationships and/or deterioration in the current relationship.  The therapist can reference the other partner for confirmation of the therapist's guesses and predictions, which helps break down denial.  The other partner simultaneously gains validation (including conceptualization) of what he or she had experienced for years in the relationship.  For both partners (it is arguable for whom it is more important), the education is critical.  Otherwise, they both remain confused as to what has actually been happening.  Helping the other partner assert a boundary or requirement of stabilization for the challenged partner is recommended.  It is important to establish boundaries for personal choices and behaviors, rather than trying to force the partner to behave in certain ways.  This reminds both partners that a personal boundary choice is followed through with a personal consequence.

Molly can refuse (and had refused previously) to be sexual with Cole unless he is more emotionally connected.  This does not force Cole to be more emotionally connected.  If he chooses not to be or cannot be more emotionally connected, Molly has complete power to follow through.  She becomes unavailable sexually whether he likes it or not.  Cole on the other hand can assert that he won't stay engaged with Molly if she yells at him.  This does not prevent Molly from yelling at Cole.  If she yells at him anyway, Cole has complete power to follow through without her permission.  Threats or ultimatums need to be distinguished from setting boundaries.  A threat or ultimatum attempts to force the other person make a specific choice or behave in a specific manner, while a boundary asserts personal behavior as a consequence following the other person's choice one way or another.  Partners can certainly recommend or promote one choice over another, but need to accept a fundamental lack of control over the other partner's choice.  The boundary has been essentially set for oneself rather than for the other person.  If major relationship boundaries or requirements are not accepted or are violated, the partner will discover if he or she had really set boundaries or merely made threats or engaged in adamant wishful thinking… or just venting.  If the partner decides to stay in the relationship despite boundary violations, the therapist must make sure he or she does so with full awareness of how he or she has given implicit permission for the behavior to continue.  The therapist may need to have him or her reexamine the condition and behaviors of the challenged partner and their effect on the relationship.  Continued presence re-establishes the boundaries- often negatively.

Hyde described a family focus treatment model where the role of the therapist is to educate the couple.  The model emphasizes how to manage the challenges that one or both partners bring into the relationship.  The focus differs from other strategies that emphasize psychodynamic exploration of unconscious roots and resultant outcomes.  Education, support and consultation serves the couple as "a means of delaying, minimizing, or preventing recurrences of bipolar disorder is the role of the family environment in the disorder's course and outcome" (Hyde, 2001, page 113-14).  The intensity and disruption of bipolar disorder on the couple is often mirrored in the high emotional reactivity from other challenges.  Hyde recommends three phases of family-focused treatment: a psycho-educational phase; a communication enhancement training phase; and a problem-solving training phase.  The principles can be applied to any pattern of high intensity disruptions.  The psycho-educational component focuses on teaching the challenged partner and the other partner or family members about the origin, nature and course of the challenge (bipolar disorder, trauma, personality disorder, and so forth).  The strategies, activities, and course of therapy for stabilization, growth, or change are described along with the theories for them.  

Huxley et al (2000) says, "…psychoeducation, relapse-prevention skills, and opportunities to discuss the experience of being ill… Patients are instructed in illness-management, detection of early prodomal indications of impending illness, identification and modification of potential stressors and interpersonal or family discord, and coping skills.  Interventions typically address matters of common concern, including denial, shame, stigma and self-acceptance, medication compliance, adverse effects of medication, substance abuse, sleep hygiene, activity schedules, general health, and themes of loss, recovery, transition, employment, relationships, creativity, and hope.  Efforts are also made to provide community education and liaison with self-help organizations" (page 137)

A psychoeducational approach may require a strong authoritative stance by the therapist.  The challenged partner and the other partner may not understand the point of psychoeducation.  They may want the problem, everything, and the acting out partner "fixed" without a lot of seemingly superfluous information.  Both Cole and Molly may consider discussing their mutual and respective issues as promoting excuses for the others misbehavior.  They may think understanding and having compassion for the other's behavior is tantamount to condoning it.  The therapist acts as a leader and trainer of the partners to assert understanding each other helps explain the behavior and removes shame.  Contrary to their fear, understanding is most effective for holding everyone responsible to work on personal change and then systemic change.  The therapist asserts that increased knowledge about the core problem is an essential initial goal.  Therapist support and partners acquiring knowledge create the developmental foundations to change.  Knowledge, understanding, acceptance, and compassion are part of a progression leading to hope and eventual change.  As it becomes logical how each had come to be, it empowers and requires each person also to make better choices.  Convincing partners such as Cole and Molly of this critical process may be a fundamental requirement for the therapist for effective therapy to follow.

The second part of therapy focuses on improving communication skills and dynamics.  The couple's communication style is affected by the stress of the challenging behavior and emotional reactivity.  The therapist needs to determine stress levels and how they affect communication between partners.  The therapist's goal is to facilitate a safe environment for teaching or instilling more appropriate working communication patterns.  Each partner is held responsible to make better choices to make interactions safer.  The therapist's ability to remain emotionally and intellectually present (mindful of personal stress levels) is often the bedrock for this aspect of therapy.  If the he or she gets swept up in the swirling energy, the therapist becomes part of the problem.  The therapist's frustration, affect, and other non-verbal presentation communicate additional stress for the couple that they do not need.  The last part of therapy is problem-solving or learning effective conflict resolution processes.  Partners need to learn to recognize when they get stuck, what are the roots of conflict, as well as how to intervene and find resolutions.  Understanding the challenging issues and how they manifest is critical to a growth process.  Included in understanding is how and why one or both partners may resist accepting the diagnosis and intervention.

Concurrent with problem solving is anticipation and preparation for potential (or probable) recurrence or relapse of challenging behavior.  Anything from a manic episode, disassociation, to acting out from a personality-disordered reaction may erupt.  Partners may assume that a final solution or "fixing" is possible, and be unprepared for a recurrence of problematic behavior.  When Molly does "it" again, Cole gets angry that Molly does not care enough not to do "it" again.  When Cole does "it" again, Molly gets angry that Cole does not care enough not to do "it" again.  Cole does not see that "it" is doing Molly, nor does Molly realize that Cole's issues are activating him.  Therapy teaches that a well-intended individual and his or her well-intended partner often cannot stop repeating negative behavior.  However, the same two partners can plan how to respond to inevitable missteps triggered by a challenge.

This is facilitated by conceptually separating the individual from his or her activating issue.  The therapist helps partners distinguish between personality traits and the challenge itself.  If partners assume that the challenge and resultant negative behavior are intrinsic to the personality of the challenged partner, harsh judgment, intolerance, or rejection can sabotage the relationship.  "Distinguishing between the two is made difficult because confusion exist with the patient, family and treatment team as to what are the baseline personality traits and what is part of the bipolar illness.  Not all clinicians agree about this effort to differentiate the patient's personality traits from bipolar.  By the time the diagnosis of bipolar illness has been made the family and the patient may have developed patterns that re-enforce dysfunctional behaviors.  Because of this confusion between personality traits and bipolar illness, much grief has resulted.  By identifying the personality patterns the therapist, patient, and the family are better able to treat the course of bipolar illness" (Hyde, 2001, page 115-16).

Hyde further recommends cognitive behavioral family therapy as an excellent method to "identify the automatic thinking, cognitive distortions and family schemas related to these patterns."  The therapist would need to determine if the cognitive behavioral therapy model that addresses patterns of behavior without directly addressing personality traits is effective.  Such a focus empowers the partners to work toward change rather than destructively focus on identifying personality based problematic traits or behaviors.  This is a very significant clinical challenge for the therapist.  An issue that is considered primarily organically based would be more readily seen as creating problematic personality traits.  On the other hand, individuals may not accept that profound stressful or traumatic experiences can prompt the development of personality traits.  The therapist should present the causal relationship between such experiences and personality traits.  For Cole and Molly, looking into the personality issues would be appropriate since their assessment excludes a bipolar disorder or other organic issue including substance abuse.  The therapist may include cognitive behavioral approaches in examining whether embedded characterological concerns prove informative to therapy.  A cognitive behavioral approach may be useful to identify non-volitional thinking and increase volitional choices for behavior.

With or without consideration of personality issues, knowledge of the process including stress vulnerability and triggers may enable the couple to agree in advance to reasonable strategies to delay, minimize, and/or prevent a relapse.  In addition, preparation can lead to agreement on what to do to interrupt, stop, or at least minimize negative behavior once it has started.  Careful examination of the process of interactions should reveal critical points that may allow interruption of a negative process.  "When they learn to understand the illness and develop functional communication patterns, the family is empowered to maintain a healthy balance and provide a safe context for the patient" (page 115).  Hyde however warns against assuming that this model is readily applicable for any person or family.  "This model is helpful in working with bipolar patients and their families.  However it seems to be culture bound.  The structure of this program did not lend itself to certain types of clients and may work best with middle to upper middle class patients.  Although this three phase model is similar to other approaches, it differs in that it emphasizes the family stress, communication training, and specifically addresses bipolar illness.  Others have applied psycho-education techniques and cognitive behavioral training to chronic mental illness.  However, Miklowitz emphasizes the role of family systems, education, communication assessment and training.  The use of family systems theory opens up the possibility of treating the system and not making the person with bipolar the scapegoat or identified patient of the family system" (Hyde, 2001, page 115).

While this model offers significant guidance to the therapist, the therapist should heed Hyde's caution and carefully assess the challenged partner and the couple or family for their amenability to it.  Important cultural factors that may interfere with this or other models may be from ethnic, religious, or other larger social and historical communities and factors.  Or, the cultural factors may derive from a family's idiosyncratic patterns of interaction.  The part of the model that encourages increased knowledge and understanding of the challenge or disorder should therefore include the therapist placing instruction within the cultural or family context of the partners.  In some situations, this may entail an instructional style comparable to that of an American professor to a class of college students, but in other situations may be more effective with a more authoritative or authoritarian style that fits authoritarian cultural models.  And in other situations, an inquisitive indirect approach may better serve connection and investment.


ADDRESS:
433 Estudillo Ave., #305
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Ronald Mah, M.A., Ph.D.
Licensed Marriage & Family Therapist, MFT32136
CONTACT INFORMATION:
(510) 614-5641 or (510) 582-5788
fax: (510) 889-6553
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