Psychotherapy with phobic patients: the marriage relationship as the source of symptoms and focus of treatment

Marital relationship and the treatment of panic disorder with agoraphobia: a critical review

The purpose of this paper is (1) to specify, among studies on the links between marital relationship and cognitive-behavioral treatment of panic disorder with agoraphobia (PDA), the conceptual and methodological limitations that may have produced inconsistent results in this field so far; and (2) to propose avenues of research that will help in remedying current weaknesses and answering important questions in this area. Following definition of PDA and a survey of its socioeconomic consequences, the authors examine results of the various ways research has tried to specify the links between marital relationship and the development, maintenance, and treatment of this disorder: the study of major life events before and after the onset of PDA, interpersonal problems and quality of marital relationship in the presence of PDA, the links between marital relationship and PDA treatment outcome, variability of experimental outcomes according to types of measure used to study these links, the effect of the spouse as co-therapist in PDA treatment, and the impact of a PDA treatment based on marital communication and problem-solving. Research hypotheses and methodological procedures are proposed to improve understanding of PDA and its treatment outcome.

Marital adjustment, intimacy and needs in female agoraphobics and their partners: a controlled study

Female agoraphobics and their partners were compared with three groups of control couples (non-phobic female psychiatric patients and their husbands, maritally distressed couples, and happily married couples) on measures relating to marital adjustment, intimacy, and needs. Neither agoraphobics nor their partners rated their marriages as more maladjusted or unpleasant than non-phobic psychiatric patients or their partner controls. Instead, agoraphobics and their spouses were found to be more comparable to happily-married couples than to maritally-distressed controls. Non-phobic psychiatric patients and their partners were generally found to rate their marriages as being as distressing and unpleasant as those of maritally distressed controls.

Marital interaction in persisting obsessive-compulsive disorders

The failure of modern behaviour therapy to relieve usefully more than 50% of severe, persisting obsessive-compulsive disorders is discussed. It is suggested that explanations for the failure of many married patients to respond to behaviour therapy can be found in their marital interaction. Where the development or maintenance of obsessive-compulsive symptoms is an alternative to overt marital conflict, it may often be counterproductive to treat the symptoms alone, since this serves to consolidate them as a displaced focus of marital dissatisfaction. Marital therapy is often unacceptable or ineffective in such cases. Five cases of persisting obsessive-compulsive disorder in married women are used to illustrate this. An innovative treatment model using spouse-aided therapy is outlined, wherein the patient's spouse is invited to take part in therapy as a co-therapist or co-agent of change.

Spouse-aided therapy in psychiatry: an introduction

This paper underlines the failure of contemporary individual and marital psychotherapies to help many married people with persisting psychological disorders. It examines the spouse's contribution to the maintenance of psychological disability, and discusses the problems of constructively involving such spouses in conjoint therapy. Spouse-aided therapy addresses this problem by inviting the patient's spouse to become a co-therapist. It is explicitly not a marriage therapy, and is conducted on a goal-orientated time-limited out-patient basis. During discussion of problems with achieving treatment goals, the focus of therapy shifts from the patient's symptoms to marital interaction. Confrontation of the spouse's contribution to the patient's continuing disability then becomes possible, and is followed by changes in marital interaction which generally facilitate the patient's improvement. Many couples choose to proceed with marital therapy after spouse-aided therapy has allowed them to reconstrue the patient's symptoms in interactional terms.

Behaviour therapy for the neuroses: some conceptual and practical problems

Some problems in reconciling behaviourism as pure science with clinical behaviour therapy for complex neurotic and personality disorders are examined. A major problem is the inability of scientific behaviourism to permit motivation, will and choice to be considered from an intrapsychic perspective. Cognitive behaviour therapy and its derivatives have been developed in an attempt to overcome this problem. Although such therapies have retained a paradigmatic attachment to behaviourism, they have more in common with psychodynamic psychotherapy. Conflict among contemporary behaviourists about the relevance of cognitive theory to behaviourism has obscured more fundamental issues such as the role of the patients-therapist relationship. Both classical and cognitive behaviour therapists view a direct examination of the patient-therapist relationship as therapeutically irrelevant, although there is evidence that such a viewpoint may be anti-therapeutic in some severe neurotic disorders. Behaviourists must acknowledge the central importance of examining the patient-therapist relationship in such disorders if they are to continue their successful dialectic with psychodynamic therapists.

The treatment of obsessional neurosis in a family setting

The limitation of a patient-centered approach to the treatment of obsessive-compulsive disorders are underlined by the failure of modern behaviour therapy techniques to help usefully more than 50 per cent of patients. The concept of family homeostasis is discussed in relation to two cases of obsessive-compulsive neurosis which failed to respond to patient-centred treatment over several years. The successful treatment of these cases in a family context is described. It is suggested that the comparative success of behaviour therapy in treating obsessive-compulsive disorders, which were previously regarded as generally intractable, has encouraged the premature use of patient-orientated behavioural techniques in cases where family therapy may be more appropriate. Although there is evidence that helping the families of obsessive-compulsive patients to verbalise feelings facilitates symptomatic improvement, the precise mechanisms whereby improvement occurs require further elucidation.