9. DepAnxiety Makes Sense-OK is Crazy - 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 9: DEPRESSION AND ANXIETY MAKES SENSE- OK IS CRAZY!


Intense emotional experiences have strong pervasive consequences for both men and women- for both partners that individuals may not be aware of.  The consequences go beyond the individual and potentially affects the other person.  Stimpson et al (2001) discussed the contagion effect, where similar to an infectious disease, partners "give" unhealthy emotions to each other.  They referenced studies of non-Hispanic white, non-Hispanic black, and Mexican American older married couples (page 386 & 387) where this seemed relevant.  The relative heath of a partner often influences the well-being of the other partner.  If one partner has physical, mental (intellectual, emotional, or psychological), spiritual, or other decline, then his or her partner is at risk to be similarly affected.  While men often believe themselves or hold themselves to be less affected or immune to emotional distress, personal self-restraint may be hiding actual distress and may be strongly affecting others in the relationship.  Mother's anxiety has been found to be significant for children's anxiety.  ''Anxiety is one of the most prominent and pervasive emotions, and large numbers of people are distressed by inappropriate or excessive anxiety'' (Rachman, 1998, p.1).  Furthermore, compared with men, ''women consistently have about twice the rates of each anxiety disorder'' (Leon, Portera, & Weissman, 1995, p. 19).  This carries implications for children, especially because maternal anxiety, but not paternal anxiety, has been found to predict childhood anxiety disorders (e.g., McClure, Brennan, Hammen, & LeBrocque, 2001).  With anxiety assessed along a continuum, Barnett, Schaafsma, Guzman, and Parker (1991) ''demonstrated the ongoing deleterious effects of high-anxiety in mothers'' (p. 436) of children studied from birth to 5.5 years... As with studies of depression (e.g., Keitner & Miller, 1990; Tamplin, Goodyer, & Herbert, 1998), the dynamics of family relationships should not be overlooked.  With an attachment theory perspective, the quality of family relationships is fundamental for security, whereas anxiety is a correlate of insecurity, throughout life (Bowlby, 1969/1982; Byng-Hall, 1995; Parkes, Stevenson-Hinde, & Marris, 1991).  Consistent with the hypothesis that 'family functioning is likely to play a major role in the etiology of anxiety disorders, both in childhood and indeed in continuation into adulthood' (Bolton, 1994, p. 403), family cognitive behavior therapy is proving highly effective with clinically anxious children and their families (Bogels & Siqueland, 2006)" (Stevenson-Hinde, et al., 2007, page 543-44).

Stevenson-Hinde, et al. (2007, page 552-53) noted that maternal anxiety was most predicted by low marital satisfaction of mothers, followed by fathers' self-rated anxiety.  In addition, the only significant predictor of maternal depression was low maternal marital satisfaction.  Mothers' perceptions of marriage and family functioning seem to be key to their anxiety and also to their husbands' anxiety.  Fathers' anxiety was most predicted their partners' perception of problematic family functioning, and then by their partner's anxiety.  Fathers' depression was best predicted by mothers' depression.  The male ratings of marriage and family functioning may not be as reliable or valid because of stereotypical gender roles and behaviors.  However, both partners tended to agree on the evaluations.  A possibility is that men's relationship satisfaction were less impactful or that they were less willing to admit the impact on their deeper emotions.  While it seems that men's depression is more separate from relationship satisfaction because of women's greater involvement in child and family functioning, the therapist should take care not to view issues in isolation.  Stevenson-Hinde et al found that "fathers' anxiety, but not depression, contributed significantly to mothers' anxiety; mothers' anxiety, but not depression, contributed to fathers' anxiety; and mothers' depression, but not anxiety, contributed to fathers' depression."  Regardless of statistical findings, the therapist needs to stay cognizant of the interactive nature of emotional and practical processes that predicts pervasive systemic repercussions to all members, with any member experiencing stress.

Having a sense of mattering to another and having someone who matters to one appears to be core human needs.  This means that depression and anxiety will be evoked and manifested most powerfully in intimate relationship systems.  Marriage or the committed monogamous relationship is often the most important intimate relationship with a significant other.  "Given its intimate, diffuse, and typically long-term nature, structural and dynamic aspects of marriage are likely to be critical in accounting or anxiety levels of both husbands and wives.  Anxiety, in turn, is presumed to have major consequences for marital adjustment and psychological well-being" (Lundren et al., 1980, page 227).  As a result, there are various models of couple therapy that treat depression (and anxiety) within a relational context, including cognitive marital therapy, strategic couple therapy, and conjoint interpersonal therapy, behavioral marital therapy for depression (BMT-D) and emotionally focused therapy (EFT; Gollman, Friedman, & Miller, 2002) (Hollist et al., 2007, page 496).  Anxiety or depression may be most commonly addressed in individual therapy, with couple therapy seen as an occasional adjunctive modality to use.  While a couple may not present for therapy wishing to work on one or both partner's anxiety or depression, one or both issues may become evident to the therapist as a major contributor to or a major consequence of relationship problems.  The therapist needs to assess the quality and depth of the depression and/or anxiety to determine whether the depression and/or anxiety are so debilitating that one or both partners of the couple are unable to be in a productive therapeutic process.  Depression and/or anxiety may essentially be a consequence of past and/or current psychodynamic issues.  Or, it may be from the couple's dysfunction and resulting lack of fulfillment or intimacy.  The therapist needs to determine if one or more of the partners is so close to the edge, that he/she is unable to receive and utilize therapeutic interventions.  Is the anxiety or depression so intense and pervasive that it fundamentally sabotages an individual's functioning in the relationship?  In other words, would intermediate stabilizing treatment possibly be indicated?  If there is a potential or apparent psychosis, panic attack, organic-induced instability or situational depression that is overwhelming functioning, including functioning in a therapeutic process, then the therapist may consider referring out to the proper professional to determine if professional treatment other than psychotherapy is indicated.  On the other hand, the therapist may find that one or both partner's anxiety or depression derive from early childhood experiences that can be processed appropriately in therapy.  In addition, therapy may take different tacks if for example, anxiety or depression is primarily a consequence of unfulfilled needs in the current relationship.

In most situations, including family-of-origin experiences, trauma, abuse, lack of fulfillment in the marriage, and so forth, the therapist should normalize the depression and/or anxiety in the individual and the relationship.

"You should be depressed if your family did that to you."

"Depressed and anxiety makes sense- OK is crazy!"

"It makes sense with all those experiences to have anxiety."

"You'd have to be comatose not to be depressed!"  

"I'd be worried too!"

When the therapist acknowledges the depression and/or anxiety of one member of couple, it powerfully validates the existential experience of the individual, confirming his/her feelings.  Therapist affirmation of the existence of depression and anxiety, of its validity, and normality expresses that he or she "gets it" about the person's feelings, and importantly, that it matters!  In other words, the feelings and the person matter.  The person's experience of depression and anxiety matters in the relationship, not only as something that causes problems, but also as an important problem for the invested attention of both partners and the therapist.  This validation of depression/anxiety and the partner's experience of them may be missing between couples that present for therapy.

Bree and Elise are a professional high upper-middle class couple.  Both were in business with Bree having a long successful history as a top sales representative for a major high tech hardware firm, and Elise venturing into import-export marketing as an entrepreneur after years as an executive in a large company.  Elise was spending a tremendous amount of time in the startup stages of her new company.  In addition, she was also investing quite a portion of their joint savings in the business.  Bree had anxiety about the risks they were taking with their savings along with concern about Elise losing time and priority with the family.  They had two elementary school age children.  Bree said that she appreciated that Elise wanted to do this project- that it was important to her, but Bree didn't see Elise having to be in such a rush about it.  Or, that they had to risk so much of their savings in it.  Elise had invested money from their savings and sold some investments without asking or telling her about it.  Bree felt ambushed when she found that money and stock was gone.   Discussion in therapy about boundaries and communication did not fully make either partner understand or really "get" the other.  The therapist asked Elise about how she came to this business venture.  Elise animatedly explained that she had always wanted to run her own business.  Her father had been an entrepreneur and had started and eventually, sold three successful businesses.  Now, he had started a philanthropic foundation and was passionately involved in its fund-raising.  Elise said that although the family was well off, she had been encouraged to make her own way, take her own risks, and find her own fulfillment.  Having just turned forty, she was excited that it was her time.  She had the experience and the contacts for her "adventure."  Elise virtually vibrated with energy as she described her plans.  The therapist said, "I kinda get how exciting and special this is for you.  It's you.  The business is you.  The business is who and what you've always wanted to be… do."  Elise nodded, feeling confirmed that at least, the therapist got her.  However, Bree didn't get her.

The ability to empathize, understand, or relate to another person often depends on one's ability to find an experiential reference within oneself.  As an individual has experienced something similar or in-kind with the other person, he or she then becomes significantly more likely and able to identify with the other.  Being triggered or provoked by an experience and feeling something intensely within oneself provides the first-person reference for compassion for the second-person's similar experience or feelings.  Bree listened to and looked at Elise as if she were observing an alien life form or at best, someone from another society and culture- as if Elise were speaking a foreign language.  Sure, she "understood" Elise.  Bree also had things she wanted to do and experience, but Elise was over the top.  The therapist decided to see if there was something comparable to Elise's experience and resultant passion in Bree's life.

The therapist asked Bree about being interested in something, getting excited, dreaming, and then working toward it.  "Did you see anyone doing that in your family?"  Bree had grown up in a working class family.  Her father worked in a factory and her mother cleaned houses.  She was one of five kids: two boys and three girls.  The boys were expected to get a job at the factory after high school.  The girls were supposed to find someone to marry- hopefully, someone with prospects.  Bree's parents didn't like uppity kids or people who thought they were better than others.  Her father had been beaten down in life.  He was a Polish Catholic in a Swedish-German Protestant neighborhood.   A high school dropout probably with undiagnosed learning disabilities (those theories didn't really exist then) and the third son of an abusive immigrant father, having a regular job was the best he hope for.  Bree's mother was a plain looking girl who was overshadowed by her vivacious and pretty older sister.  Little was expected of her and she learned not to expect much of herself.  It had been tough coming to terms with her sexuality, and of reconciling it with family expectations.  After going through all that, Bree felt fortunate to have a partner who didn't drink, and who came home after work, gave her the check, and didn't hit her.  Bree had learned to set low goals from both parents.  Bree told the therapist she didn't have any dreams or aspirations when she was young.  She was supposed to get married to a decent guy.  Bree had just come to recognized that it had to be a decent gal when in an unexpected fortuitous accident, the gorgeous college junior Elise had stopped for a burger at the café she was waitressing at during high school.  Bree couldn't believe or hope that confidently out and confident Elise was interested in her.  Elise was more than she had ever hoped for in a partner.  She couldn't hope that their fling would last.  Even when Bree followed Elise when she moved to another college for graduate work, Bree didn't think it would happen for her.

Taking community college classes, Bree discovered that she was a decent student.  A job in an office led to doing some presentations for the boss.  Always a hard worker, Bree excelled and was promoted again and again.  Over the years, she had become a top salesperson in a number of companies.  She had advanced and succeeded despite never really believing in herself.  Many times, when Elise encouraged her to take a promotion or take a risk, Bree was able to only by telling herself that she'd give it a try and see what happens.  Indulging in hopes and dreams of greater achievement or opportunities was against her code.  It was against the family code.  Always vigilant that the good times would end, Bree never could "stop and smell the roses."  Anticipating the dark side was how the family tried to keep it at bay.  Despite her successes and going well beyond her and the family expectations of her, Bree constantly struggled to keep anxiety and depression at arm's length.  "No," Bree told the therapist, "We were taught to go for the sure thing.  I never learned to take risks… it was too scary.  Trying to start a business from scratch like Elise is beyond me.  That's why I've chosen to work for big companies.  It's more of a sure thing."  The therapist turned to Elise and asked, "Did you realize that Bree's never been able to risk the passion to take the chance?  How does that make you feel?"  Elise teared up, "I didn't know.  I know how much it gives me… to go for it.   The rush… the adrenaline… and the satisfaction of making it happen.  It makes me sad that Bree's never had the experience."  She reached over and held Bree's hand.  The therapist asked Bree with a little smile, "So, how'd Elise do?  Did she get it?"  A bright smile spread across Bree's face, "She got it.  She did pretty good!"

The other non-depressed or non-anxious partner- Elise in this case, may have denied or been ignorant of the first partner's depression or anxiety.  Hearing the therapist identify and validate his/her partner's depression and/or anxiety takes him/her beyond grievances about the depressed or anxious partner.  Up until then, the non-depressed or non-anxious partner may have so immersed in his/her own distress, disappointments, unfulfilled needs, passions, and goals that he/she had not recognized the partner's depression or anxiety.  This is a first step towards building empathy that may have not existed before.   Elise got Bree.  Bree got herself.  This created the possibility for Bree to get Elise in return.

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