Anxiety Disorders in Couple and Family Therapy
Anxiety disorders encompass a diverse set of psychological disorders. The current edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association 2013) recognizes seven distinct disorders within the category. These disorders are generally characterized by the presence of fears (defined as perceptions of imminent threat), anxiety (defined as worry regarding future threat), chronic tension, cautiousness, avoidance, and related behavioral disturbance. In addition to these symptoms, anxiety disorders also share mechanisms underlying their etiology and maintenance, although there is considerable heterogeneity in how these disorders present. One implication of these shared mechanisms is that there is relatively high comorbidity among anxiety disorders. Anxiety disorders are also particularly common in the general population, with lifetime prevalence estimates nearing 30% in the United States (Kessler et al. 2005).
Due to their high prevalence, many individuals may be relatively familiar with anxiety disorders. However, misunderstandings still abound regarding how best to care for individuals struggling with these disorders. Without being involved in the treatment process, family members and significant others may attempt to reassure and care for their loved one, which may actually undermine the effectiveness of certain treatments, such as exposure therapy. Therefore, it is important for clinicians to consider incorporating a couple- and/or family-based perspective to their approach when treating anxiety disorders.
There is evidence to suggest that couple-based approaches are effective in reducing both anxiety symptoms and relationship discord (Whisman and Robustelli 2016). Attending to both anxiety symptoms and relationship discord in treatment is important, due to the potential for each to maintain and promote the other. Research suggests that couple-based interventions are effective in treating posttraumatic stress disorder (PTSD) and obsessive compulsive disorder (OCD), which were both included in the anxiety disorder category in previous editions of the DSM. To date, little research has examined couple- or family-based treatment for other anxiety disorders.
Theoretical Context for Concept
Anxiety disorders are generally thought to arise when the human capacity for learning and avoidance goes awry. When appropriately matched to the dangers at hand, these learning and avoidance processes can have adaptive functional outcomes (e.g., learning not to touch a hot stove). However, when fear associations and avoidance behavior grow out of proportion with the actual danger posed or generalize inappropriately, the benefits can quickly be outweighed by significant negative life consequences (e.g., becoming fearful of burning the house down to the extent of refusing to turn on the heat in the winter).
Avoidance in the face of true dangers can be vital for survival. However, this same process can also drive clinically relevant anxiety by removing opportunities to challenge beliefs upholding fears. Fears are typically based in catastrophic beliefs about the outcome of specific situations (e.g., that a future panic attack will lead to death, as seen in panic disorder; that an individual will be rejected and embarrassed if evaluated by others as seen in social anxiety disorder). Therefore, gaining experience with the feared situation or stimulus and seeing that the fears do not “come true” provide compelling evidence against the belief and form the foundation of effective anxiety disorder treatment. However, individuals with anxiety disorders avoid the perceived dangers and therefore the opportunity to collect evidence against the beliefs underlying their anxiety. In fact, when engaging in avoidance, the fact that the fear does not “come true” is attributed to success of avoidance as a countermeasure.
Although avoidance is typically considered an individual endeavor, it is also important to consider how interpersonal relationships may help promote avoidance and maintain fear beliefs. It can be difficult to observe a loved one suffering from distressing anxiety symptoms. For example, a spouse may attempt to relieve anxiety symptoms of their partner associated with social anxiety disorder (social phobia) by accommodating the partner’s avoidance of social gatherings or other social situations that create discomfort. It is understandable that family members want to relieve their loved ones of their symptoms of anxiety and make them feel less distressed. Although these behaviors may be intended to be supportive, they do not actually help to eliminate the fears and can serve as interpersonal safety behaviors. Thus, it is important to consider the role of relationship partners and other family members in understanding and treating anxiety disorders.
There are several reasons why couple- or family-based treatments may be effective treatments for anxiety disorders. On one hand, relationship or family discord may increase the likelihood of a person experiencing anxiety. For example, conflict between partners may be stressful, thereby increasing the risk of experiencing symptoms such as worry or anxiety about one’s relationship. On the other hand, symptoms of anxiety may increase the likelihood of relationship problems. For example, if a person with social anxiety disorder (social phobia) chooses not to attend social gatherings that their partner wishes to attend, that may strain their relationship, thus increasing the likelihood of poor relationship functioning. Finally, symptoms of anxiety disorders and relationship functioning may exert a bidirectional influence. Therefore, individuals with an anxiety disorder may exhibit behaviors that bring about relationship discord, which in turn perpetuate anxiety about the state of the relationship, which can in turn exacerbate behaviors and symptoms that can strain the relationship. Thus, the interplay of anxiety symptoms with couple and family functioning is likely to be complex.
Epidemiological studies suggest that marital discord is positively associated with symptoms of anxiety (Leach et al. 2013) and that lower levels of marital adjustment are reported by people with anxiety disorders, including people with generalized anxiety disorder (GAD), PTSD, and social phobia (Whisman 2007). One longitudinal population-based study found that lower marital quality was associated with an increased risk for incidence of social phobia at a 2–3 year follow-up (Overbeek et al. 2006). Much of the research on couple functioning and anxiety has focused on PTSD. PTSD is associated with relationship discord and perpetration of both psychological and physical aggression against an intimate partner (Taft et al. 2011). In addition, lower relationship quality and higher psychological distress are reported by partners of individuals with PTSD (Lambert et al. 2012). With respect to family functioning and anxiety in children, there is a modest association between parenting and childhood anxiety, with parental control more strongly associated with childhood anxiety than parental rejection (McLeod et al. 2007). However, most studies on parenting and childhood anxiety are cross-sectional, so it remains unclear whether negative parenting behaviors precede the development of childhood anxiety, are elicited by childhood anxiety, or are the result of some “third variable.” Taken together, research findings suggest that couple and family problems are likely to be common for people with anxiety disorders.
Several theoretical approaches have been developed to involve partners or other family members in the treatment of anxiety disorders (Whisman and Robustelli 2016). Whereas some treatments are indicated for use with specific anxiety disorders, others have broader treatment applicability. Cognitive-behavioral conjoint therapy (CBCT) has shown to be an effective couple-based intervention for the treatment of PTSD. CBCT targets both PTSD symptoms as well as relationship functioning by providing psychoeducation regarding PTSD, communication skill training for improving relationship adjustment, behavioral approach activities to counter avoidance, and cognitive interventions that aim to address beliefs that reinforce sources of relationship problems and PTSD symptoms. Including partners or parents in couple- or family-based interventions has also been shown to be effective in treating OCD. This treatment supplements individual cognitive-behavioral therapy with couple- or family-assisted exposure, response prevention for accommodation, and communication training. Emotionally focused couple therapy (EFT) is another couple-based approach with evidence suggesting it may be an effective treatment for couples in which one partner has symptoms of PTSD. In EFCT, couples learn to identify and understand emotions related to trauma and those that are related to relationship discord and work to form a supportive emotional connection. Another couple-based approach to PTSD is strategic approach therapy (SAT), which targets both avoidance symptoms associated with PTSD and enhances communication and healthy relationship skills.
Application of Concept in Couple and Family Therapy
The majority of couple- and family-based approaches for anxiety disorders share several key components. In order to develop a treatment plan, it is first necessary to assess the individual’s anxiety symptoms and the impact of these symptoms on the individual’s functioning in multiple domains, including their intimate and family relationships. In addition, it is important to identify behaviors that both individuals and their partners or other family members enact to maintain their anxiety. As previously discussed, by attempting to decrease a person’s distress or to minimize conflict related to a person’s symptoms, partners or family members may inadvertently reinforce anxiety, so a thorough accounting of these maintaining factors is an important component of the assessment phase of treatment.
Another common component to couple- and family-based approaches is psychoeducation. Just like individual treatments, couple- and family-based treatments involve general psychoeducation about the nature of anxiety, as well as specific topics of interest such as reinforcement learning and avoidance. However, psychoeducation in couple- and family-based approaches is also likely to include a discussion of the ways in which a partner or family member may actually be reinforcing an individual’s anxiety symptoms. Given the bidirectional effect of anxiety and couple and family functioning, psychoeducation also generally includes education regarding the ways that anxiety symptoms can negatively impact and be impacted by couple and family functioning.
Other components to couple- and family-based approaches to anxiety disorders include interventions to enhance relationship adjustment. Specifically, couples typically learn ways to enhance their relationship functioning, including ways to improve communication and problem solving and ways to enhance intimacy and feelings of connectedness. These skills help couples become more resistant to relationship distress that may occur due to anxiety-related stressors or anxious cognitions. At this point, treatments may vary in foci. Treatments such as CBCT and SAT rely on partner-assisted exposures in which the partner is taught how to guide exposures and facilitate new learning to extinguish safety behaviors. Other treatments like CBCT utilize cognitive interventions to target maladaptive beliefs that may impact both relationship functioning and PTSD symptoms. EFCT focuses on helping couples identify problematic relationship patterns and understanding how trauma-related emotions contribute to these patterns. Once those are identified and better understood, couples work to enact more positive patterns of interaction.
Caroline presented for therapy for PTSD following a sexual assault she experienced the previous year. Although she originally presented for individual therapy, she and Joshua, her husband of 7 years, were receptive to the therapist’s suggestion to pursue couple therapy (i.e., CBCT for PTSD; Monson and Fredman 2012). The first phase of therapy focused on providing psychoeducation about PTSD and how it was impacting the couple’s relationship. In the second phase of therapy, the couple learned and practiced communication skills to identify and share their thoughts and feelings with one another and used these skills to increase emotional intimacy and reduce PTSD-related emotional numbing and avoidance. They also used these communication skills to identify people, places, situations, and feelings they were avoiding as a couple as a result of Caroline’s PTSD. Both partners reported “walking on eggshells” when they were around one another, and they identified a variety of things they were avoiding (e.g., going out in public, physical affection, sexual behavior, talking about the assault). This “avoidance” list became their “approach” list, as each session they identified things they could do during the coming week that would not only reduce behavioral and experiential avoidance but also serve as rewarding activities. They started with the approach activities they thought would be easiest and included other activities over the course of therapy. In the final phase of therapy, in addition to increasing the frequency of approach behaviors, therapy focused on identifying and modifying trauma-related cognitions. In CBCT, cognitions that either partner holds that maintain PTSD or relationship distress are challenged together as a couple. The initial focus of the cognitive work for Caroline and Joshua was on cognitions related to the traumatic event (e.g., Caroline’s recurring thoughts about how she should have been able to “see the assault coming” and how she could have prevented the assault). The therapist helped Caroline and Joshua work together to generate alternative ways of thinking about the assault (e.g., by reviewing how the assault occurred, Caroline came to see that she couldn’t have predicted it in advance or prevented it). Over the course of several sessions, the focus of the cognitive work was expanded to include interpersonal beliefs that were a result of the trauma (e.g., Caroline would never be able to trust Joshua, the couple would never be comfortable having sex again). At the end of therapy, Caroline reported a substantial decline in her PTSD symptoms, and both partners reported an increase in their relationship satisfaction.
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