6. Stressors DepAnxiety Marital Distress - RonaldMah

Ronald Mah, M.A., Ph.D.
Licensed Marriage & Family Therapist,
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I Don't… You Don't… It Don't Matter, Depression and Anxiety in Couples and Couple Therapy

Relationship dissatisfaction and depression/anxiety mutually affect each other.  Depressed or anxious individuals make choices that add stress to their lives, which increase their experience of depression/anxiety.  In a couple, a depressed or anxious partner can behave in ways that increase relationship problems, which in turn increases his or her depression/anxiety.  Thus, depression or anxiety are both causes and consequences of relationship dysfunction.  "…evidence for the stress generation model applied to marriage has been found across women (Davila et al., 1997).  Marital discord model of depression (Gotlib & Beach, 1995) suggests that marital discord, manifested in decreases in various types of adaptive behaviors and increases in negative behaviors, leads to subsequent depression, which is then manifested in further maladaptive types of interpersonal behaviors and, ultimately, further marital discord" (Goldfarb, 2007, page 111).  Goldfarb reported a number of problematic behaviors and characteristics that create stress, depression/anxiety, and relationship discord.  Deficits in problem solving skills and behaviors significantly predict depressive symptoms for both men and women.  In couples with an outpatient depressed wife, coping behaviors for problems were less constructive and more destructive those without a depressed partner.  Depressed wives showed fewer positive family interactions than depressed husbands even when depressed husband showed greater severity of depressed symptoms.  Depressed wives solicited, received and provided support more negatively when interacting with their husbands.  Depression is related to not performing various family or work roles, including less participation in home activities with greater depression for women but not men.  However with couples with both partners working full-time, marital-role quality and depression are associated for both women and men.  Variability in personality styles such as "sociotropy and autonomy (Beck, 1983, in Lynch et al. 2001) or dependency and self-criticism (Blatt, 1974, in Whiffen & Aube, 1999) are related to depression as well as to interpersonal dysfunction.  High need for affiliation (sociotropy/dependency) is hypothesized to be associated with depression following interpersonal losses, and high need for independence and achievement (autonomy/self-criticism) with depression following achievement losses" (page 111-12).  Individual variation may increase or decrease sensitivity to different types of stress or likelihood to initiate stress through conflict.  It is likely that negative behavior of partners can maintain and intensify problematic styles, thereby exacerbating increasing symptoms indirectly.  Demand-withdraw styles of interaction are associated with both depression and relationship distress.  These stylistic or characterological responses to stress, depression/anxiety, or relationship problems have potential to build upon themselves with any challenge.  There are characteristic challenges that many couples face that the therapist should be aware of.

A major stress on the relationship with accompanying depression and anxiety would be the diagnosis and treatment of life threatening illnesses.  For example, "Diagnosis and treatment of breast cancer are life-altering experiences that may evoke considerable emotional distress in patients and their intimates.  Feelings of anxiety and depression may be understandable reactions to the changes imposed by the illness and its treatment- threat of death, loss of mobility, tiredness, or changes in social and leisure activities.  Moreover, when high levels of distress persist over time, they may become the focus of clinical concern.  Claims are widespread that cancer may induce enduring high levels of distress in patients and partners" (Hinnen et al., 2008) page 141).  Personality or background factors can have implications for the degree and quality distress, and subsequently for cognitive, emotional, and psychological interventions.  One of the basic dimensions in the Big Five model of personality is neuroticism, which is indicative of emotional instability.  It increases vulnerability to distress in general and specifically in stress situations.  Neuroticism is considered to be relatively stable over the life span.  "Moderate to strong correlations have been found between neuroticism and distress, raising discussion about possible contamination.  Several studies have shown that, while distress was susceptible to change as a result of life events, neuroticism remained stable, favoring its position as a trait.  In addition, it was found that neuroticism is a predictor of the distress induced by life events, supporting its importance when examining distress" (Hinnen et al., 2008, page 142).  The therapist should determine if a partner is prone to neuroticism from examining his or her developmental history.  Although neuroticism is considered relatively stable over time, there still may be early formative experiences at its core.  It is notable that both individuals and couples show remarkable variability in how they handle life threatening experiences and illnesses.  The therapist may consider if one or both partners' expectations of calm to reactive to measured to hopeless reactions are based on realistic capacities or idealistic desires.  A calm response rather than reassuring may instead be disturbing to a partner facing a medical crisis who expects more overt emotional reactions.

On the other side of the spectrum of dealing with potential death is the creation and beginning of life.  Serrano and Lima (2006, page 586) note that feelings of guilt are also common after the loss of a miscarriage.  After a miscarriage, some women may blame themselves which can intensify their grief.  In searching for meaning with a miscarriage, blaming themselves may be an unexpressed complication that partners may not be aware is blocking the resolution of grief and loss.  In this and with all situations, the therapist may wish to consider the relative influence of predisposition (prior anxiety or depression or neuroticism for example) and the traumatic event.  Schmidt (2006) studied couples who attempted in-vitro fertilization (IVF) and found significant differences between women who became pregnant versus those who completed three cycles without achieving a pregnancy 6 months later.  Not surprisingly, women who had not become pregnant had significantly higher levels of anxiety and depressive symptoms, poorer marital functioning, and higher levels of non-communication and dissatisfaction with their sexual relationship.  Male partners of women who did not get pregnant were also affected, reporting greater depressive symptoms and lower relationship satisfaction.  After the last unsuccessful treatment, anxiety and depression increased in women and persisted 6 months later.  In contrast, there was no significant change in anxiety and depression in men.  In addition, after the failure of IVF, women were more dissatisfied with the marital relationship. (Schmidt, 2006, page 379).  Considering the cultural emphasis for women as defined as wives, as mothers, and in the family, it should not be surprising that failed pregnancy has strong negative effects on women and the couple.  

On the other hand, successful birth, children and family issues can also dramatically stress women and subsequently, the couple.  "In general, having children reduces marital quality while paradoxically increasing stability (Bradbury, Fincham, & Beach, 2000).  But does the addition of a child to the family impact how couples handle problems and the subsequent quality of the marital relationship?  The last trimester of pregnancy brings with it lower levels of physical affection and higher levels of conflict (Belsky & Pensky, 1988), leading first to a decline in women's, and later men's, marital satisfaction (Cowan & Cowan, 1992).  Fortunately, for couples in relatively harmonious marriages, the arrival of a child does not have a serious impact on marital quality in the long run; nonetheless, couples who have difficulty prenatally are also more likely to experience problems after the birth of a child (Belsky & Pensky, 1988)" (Houts, 2008, page 103).  How well couples problem-solved while "expecting their first child and during the 2 years following birth predicted whether or not they remained married 5 years after the birth.  Couples whose problem-solving style was Always Constructive were particularly protected relative to couples whose problem-solving style was Mixed or Always Destructive" (Houts, 2008, page 118).  This may be interpreted that coping styles are predisposed or habitual, but may not be activated to an intense degree until a compelling challenge or crisis arises.  In other words, partners and the couple may not have gotten any worse in dealing with stress, but that pregnancy, birth, and child raising stress may be qualitatively different or substantially more intense.  The implicit meaning of each stage and progression may bring greater emotional, psychological, intellectual, or spiritual complexity than heretofore experienced.  Individual couples tended to remain stable in their problem solving styles throughout the 2 years of Houts' study.  Houts found that 52% of couples Always Constructive, 28% Always Destructive, and 20% Mixed.  Minor statistical changes tended to occur between prenatal and 3-month past birth and beyond.  "This overall pattern of Constructive and Destructive conflict styles from the prenatal period through the child's second birthday is consistent with the notion that the late prenatal period may be a honeymoon of sorts for some couples.  Yet, once the realities of adding a child to the family become undeniable, tempers may flare and couples become less 'cautious' about how they deal with their difficulties, leading to an increase in the relative frequency of Destructive conflict tactics at the 3-month assessment" (Houts, 2008, page 118).  The therapist may find exploring preconceptions of life with newborns or children useful.  In particular, if either or both partners had an idealized set of expectations for parenthood.

Gene and Josie, both in their late thirties had children in their mid to late twenties.  Josie came from a large family with a stay-at-home mom.  Gene was an only child whose parents divorced when he was a preschooler.  He was raised by a succession of nannies.  Among their issues was Gene's dysthymia that he ascribed to Josie not spending enough time with him.  Josie said that Gene's job was to bring home the money and her job was to make the home and take care of the children.  With exploration, Gene revealed that they had been great play buddies up until they had children.  Josie has more or less asserted that now as parents, they needed to be responsible and focus on household needs and parenting.  No time to play and thus, they were not play buddies anymore.  While Gene understood and accepted that, he felt that Josie didn't even consider his emotional needs as a partner but dedicated herself completely to the kids.  Josie basically said Gene's interpretation was correct and that she had no guilt about it.  He was a "big boy" now, and the real little kids needed her attention and focus.  

Therapy needed to look into deeper exploration of Gene's expectations of couplehood and couplehood with children.  The therapist will often find that a client will have a strong self-definition that he or she compares real life to.  The sense of who he or she should be, including how he or she and most critically how others in the couple or family are supposed to act is often held in secret.  Specific directed attention to this allowed Gene and Josie to discover that he had strong idealized expectations of being a great dad (which included being a great wage earner and spending quality time with them- he did these things), having a great family with great kids, and still having a great play partner in his wife Josie.  Having never experienced how a father or a pair of parents balanced individual, couple's, and family needs (as Josie had experienced in her family), his idealized family life expectations crashed against their reality.  Gene had been very excited to have children.  And initially, he was as caught up in the euphoria of it as everyone else.  However, as weeks became months, he found he was missing something from Josie.  The therapist will often find a client who has disappointments and may hold grievances about the partner bases on expectations that had never been overtly discussed, much less negotiated.  "Following the birth of the first child, husbands may be more aware of the changes in marital intimacy due to the time that having a baby takes away from the marriage and the relationship between spouses.  When Destructive interaction patterns (e.g., tension, hostility, withdrawal, lack of validation) intensify the adjustment process, even intermittently, husbands' views of the marriage may become more negative (i.e., ambivalent and conflicted) and less positive (i.e., less intimate and satisfying).  Wives, in contrast, may be so emotionally focused on the needs of the child that they are initially impervious to intermittent Destructive problem-solving tactics (Belsky & Kelly, 1994).  This lack of impact on wives' marital views appears to diminish over time, with the Mixed wives reporting negative views of their marriage similar to the Always Destructive wives by the child's fifth birthday" (Houts, 2008, page 119).

Therapy focused on problem solving how to find balance within their many life demands would not have been sufficient for Josie and Gene.  Josie for one, did not and had not experienced the change in their relationship, or she had accepted it as a necessary and reasonable sacrifice for their new stage of parenthood with young children.  Realistically, as long as there were functional requirements of a household with pre-teen and teen children to balance, Gene would never be able to realize his idealized play partner relationship with Josie.  Proceeding with problem solving time would have ignored Gene's sense of profound loss, much less address potential beliefs held by Josie that caused her to be somewhat unsympathetic to his requests.  As long as Josie felt that Gene was being selfish and asking her to betray the mother she needed to be, Josie would not have participated willingly in a problem solving process anyway.  Josie had a definite sense of self as a mother.  Therapy needed to process how Gene came to his idealized partner relationship and what it meant to him.  Once this was accomplished, then it became possible for therapy to find appropriate satisfaction for his needs otherwise.  Appropriate satisfaction would have to honor Josie's need to mother as she felt necessary and deal with balancing practical issues in the household.  Since Gene's issue and sense of loss had begun many years ago with birth of their children, the therapist may need to also track the evolution of their problem solving styles over that time.  In particular, if they began with Constructive problem solving styles and move to Destructive problem solving styles, vice versa, or flip-flop between styles, they may be particularly vulnerable to marital distress and separation and divorce.

"Although these couples inevitably adapt to the addition of the child into the family, the reorganization they experience in the marriage is not necessarily stable and may, in turn, result in more complex or vulnerable interaction patterns (Cox & Paley, 1997).  For example, some couples may experience disillusionment when the reality of having a child does not match their expectations.  The pregnancy period may be experienced as a 'honeymoon' time in which partners are more attuned to each other's needs and experience idealized visions of what adding a baby to their relationship actually means (Cowan & Cowan, 1992).  Following the arrival of the child, the reality of the many decisions and adjustments required to integrate a child into the family (e.g., reduced sleep, if and when to return to work) may lead to a loss of romance and increased distress.  In support of this view, the transition to parenthood decreases broadly defined marital quality (Belsky, Lang, & Rovine, 1985; Cowan et al., 1985; Feldman & Nash, 1984), especially if the partners experienced concurrent depressive symptoms, if the child was female, or if partners lacked positive problem-solving communication prior to the birth (Cox et al., 1999).  These findings support the idea that the transition to parenthood may be a time in marriage that is particularly susceptible to marital distress and instability, especially if couples have a difficult time maintaining their earlier interaction style or the new interaction pattern brings with it new vulnerabilities" (Houts, 2008, page 105).

Couple therapy for Gene and Josie could be further complicated by or move into the issue of Gene's long existing and ongoing depression (Dysthymic Disorder, if using DSM-IV diagnoses or persistent depressive disorder in DSM-V) from childhood issues of abandonment and resultant attachment losses.  Gene had always functioned well enough, including doing well in school.  But his emotionally and/or physically unavailable parents and repeated losses and feeling of being abandoned from a series of nannies who left after one to three years had left him feeling sad and unloved… and anxious about being left behind again.  Josie's harsh and unsympathetic response that he was a "big boy" fulfilled his fear.  Practically speaking, her behavioral response did nothing for him.   Hurt by her dismissal, Gene's resentment lead him to being critical of her household choices, her clothes, her weight, and just about anything else.  "For wives, being in a marriage whose problem-solving style was Always Destructive was particularly detrimental to concurrent mental health and views of the marriage.  Women in these relationships reported more depression, more negative views of their marriages, and fewer positive views of marriage than women in marriages whose problem-solving style was Always Constructive or Mixed.  For husbands, mental health followed a pattern similar to wives, in that the Always Destructive pattern related to higher depressive symptoms.  In contrast to wives, being in marriages whose problem-solving style was Always Constructive proved most protective for husbands in terms of concurrent self-reported marital functioning.  These husbands reported fewer negative and greater positive views of the marriage than Always Destructive or Mixed husbands" (Houts, 2008, page 118-19).

Gene was depressed and somewhat anxious.  Josie could have shown similar negative affect.  However, she had largely abandoned seeking emotional fulfillment from Gene.  Instead, she drew upon the affection and energy given and received in her mother-child relationships.  Josie's willingness to come to couple therapy was motivated by her anticipation of an "empty nest" as the children were already becoming more independent of parental attention.  Her underlying dissatisfaction with the couple's relationship combined with anticipatory depression and anxiety about impending losses when they would leave the nest.  The therapist may need to determine if the destructive communication style of both partners predated the change in their family composition or caused it.  Therapy would need to adjust depending on what the therapist discovers.  If the style comes from the issues and circumstances in the relationship, healing would be largely facilitated between the partners.  If on the other hand, it comes from family-of-origin or earlier relationships, then the deeper wounds would need to be addressed including how they flare up with and towards one another.  With strong predisposition or deep early emotional/psychological wounds, identifying potential stressors may have some but limited usefulness therapeutically without closer individualized examination.

433 Estudillo Ave., #305
San Leandro, CA 94577-4915
Ronald Mah, M.A., Ph.D.
Licensed Marriage & Family Therapist, MFT32136
phone: (510) 614-5641
fax: (510) 889-6553
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