Helping Couples Improve Their Relationships

1. Helping Couples Improve Their Relationships MARRCH Annual Workshop1-2:40 & 3-4:40 pm 10/30/07 Doug Greenlee MA/MS LMFT, LADC, CGC Staff Psychotherapist, Recovery Plus Addiction & Mental Health Center Greenleed@centracare.com

2. Goals & Objectives • To highlight biopsychosocial evidence-informed relational enhancement models that may be useful for reducing conflict and enhancing intimacy skills in couple and/or family relationships • To provide opportunity for attendees to review and to discuss sample case scenarios via practice identifying basic issues, implementing problem solving and enhancing intimacy skills development

3. Logistics • Learning level: Beginner • Core Functions: Counseling & implications • Presenter Information: Experience & Education • Presentation summary: Evidence-informed relational enhancement models • Client? • Cultural Diversity: Client as Cultural Unit • Ethics: Informed consent, confidentiality limits, dual licensure & gray areas

4. Overview

5. Biopsychosocial Overview(Campbell, W. & Rohrbaugh, R., 2006) Biological/Descriptive Data Base • Symptoms: Mood, Anxiety, Cognitive, Substance, Psychotic, Personality, Somatic • Predispositions: Genetics, Physical Conditions, Medications/Substances • Demographics: = disorder & epidemiology

6. BPS cont. Psychological Formulation • Vulnerabilities: developmental disruptions, revelatory statements/behavior, recurrent relationship difficulties • Psychosocial Stressors: Why Now?

7. BPS cont. • Psychic Consequences: Strong emotions, thoughts/fantasies, subtle changes in cognition • Coping mechanisms: Adaptive, maladaptive • Psychodynamic Formulation: Dependency, Control, Self-esteem, Intimacy/triadic relationships

8. BPS cont. • Cognitive Perspective: Dysfunctional automatic thoughts, Negative core beliefs, cognitive distortions • Behavioral Perspective: Reinforcement for maladaptive behavior? Something extinguishing a desired behavior? Paired association between behavior/environmental cue initiating behavior?

9. BPS cont. Social Formulation/Database • Social Stressors & Strengths: Family, SO/friendships, social issues, education, work, housing, income, health care access, legal/crime • Cultural/Spiritual: C/S-- identity, explanations of illness, psychosocial environment/functioning level, therapeutic alliance dynamics

10. BPS cont. Prognosis • Compliance with treatment • Response to prior treatment • Availability of treatment • Personality/defense mechanisms • Social supports

11. Addiction Science Overview(Erickson, C., 2007) Brain Disease • Nervous system functions: Sensing, integrative, & motor • Nervous system: CNS, PNS • Neurochemicals: Dopamine, Serotonin, Norepinephrine, Acetycholine, Endorphins, Endocannibinoids, Glutamate & Gaba • Reward pathway: Mesolimbic Dopamine System • Disease: Genetic vulnerability, neuroadaptation synaptic plasticity & sensitization/desensitization, dysregulations

12. Addiction Science cont. Neurobiological Theories of Dependence • Allostasis • Pathology of motivation and choice • Incentive socialization • Learning and memory mechanisms

13. Affective Neuroscience(Atkinson, B. 2005) The Emotional Brain • Neural architecture favors emotional influence • Rational decision making emotion dependent • Brain/emotion mechanisms • Emotional memory • Neural back alley • Unconscious emotional influence • Neural hijacking

14. Affective Neuroscience cont. Integrating Neural Knowledge • Cultivate greater awareness of emotional influences • Treat emotional states as if they had minds of their own • Attend to emotional states before pursuing other therapeutic goals • Focus on the stance clients take toward their emotional states • Work with emotional states when they are active • Seek cooperation from not control over emotional states

15. Affective Neuroscience cont. Special Purpose Mood States • Executive operating systems: “State of mind is a pattern of activation of recruited systems within the brain responsible for: 10 perceptual bias, 2) emotional tone & regulation, 3) memory processes, 4) mental models, 5) behavioral response patterns.” • State activation: motivation to accomplish critical survival tasks

16. Affective Neuroscience cont. Brain’s Executive Operating Systems • Rage: Evolutionary advantage/self-protection • Fear: E/A - escape danger • Seeking: E/A – learning/agency in the world • Lust: E/A – motivation to reproduction • Care: E/A – protection of loved one’s • Panic: E/A – motivation for affiliation/support • Play: E/A – social bonding, creativity, healing

17. Co-Occuring Disorders Marital Distress & Psychiatric Disorders Epidemiological Study (2000) • Major depression • Social Phobia • Simple Phobia • Panic Disorder • Generalized Anxiety Disorder • Alcohol dependence/Abuse

18. Attachment Dynamics

19. Cultural Competence Process & Health Care Cultural Competence Healthcare Models • Campinha-Bacote Model: Desire, Awareness, Knowledge, Skill & Encounter (see handout) • Purnell’s model for cultural competence: Unconsciously incompetent; Consciously incompetent; Consciously competent; Unconsciously competent.(see handout)

20. Sequential & Pluralistic Couple’s Therapy Process Model • Examine developmental sources of relationship distress • Challenge cognitive components of relationship distress • Promote relevant relationship skills • Strengthen the couple dyad • Contain disabling crises • Establish a collaborative alliance

21. Therapeutic Alliance Transtheoretical Dimensions • Engagement in the therapeutic process • Emotional connection with the therapist • Safety within the therapeutic system • Shared sense of purpose within the family

22. Therapeutic Alliance cont. SOFTA-O: System for Observing Family Therapy Alliances—Observational • Engagement: Client/Therapist version • Emotional Connection: Client/Therapist version • Safety: Client/Therapist version • Shared Purpose: Client/Therapist version

23. Partnership(Dr. Jan Hoistad) Basic Styles • Traditional – dominant & non-dominant • Merged – fused personal boundaries • Roommate – independent & unilateral • Big Picture Partnering – your, my & our world

24. Big Picture Partnering:10 Essentials • Create & maintain positive feelings • Talk regularly & take turns listening • Regularly renew your commitment • Stay committed to Big Picture • Make win/win decisions • Pull your own weight • Make & keep clear agreements • Partnering is joint effort • Problem solve relationship together • Create new options

25. The Four Horseman of the Apocalypse • Criticism • Defensiveness • Contempt • Stonewalling

26. RelationalSuccess Managing Conflict • Prerequisite: 1 Soft Start-up • Prerequisite: 2 Accepting Influence • Prerequisite: 3 Effective Repair • Prerequisite: 4 Respecting Partner’s Dreams Connecting During Non-Conflict Times • Prerequisite: 5 Five Positives – 1 Negative

27. Relational Success: Predictive Habits Soft Start-Up • Avoiding a Judgmental Attitude • Standing Up for Yourself Without Putting Your Partner Down Accepting Influence • Finding the Understandable Part • Giving Equal Regard

28. Relational Success: Predictive Habits Effective Repair • Offering Assurances Respecting Your Partner’s Dreams & Holding on to Your Own • Understanding & Explaining What is at Stake

29. Relational Success: Predictive Habits 5 Positives for Every Negative • Curiosity about Your Partner’s World • Keeping Sight of the Positive • Pursuing Shared Meaning • Making and Responding to Bids for Connnection

30. Common Issues • Workaholic – Where do we fit? • The Affair – Can I/we get over it? • Crises – Yes! Problem solving but intimacy? • Stonewalling – Why don’t we talk anymore? • Dream loss – What about my/our dreams? • Depressed – Why so distant & irritable? • Frustrated – So, I’m a nag? • Dead-in-the water – Where’s the fun? • Children-focused – What about Us? • Dramatic – Is it really that complicated?

31. Conversation Practice • Living Your Dreams Together: Conversation Cards for Couples by Dr. Jan Hoistad • The Art of Conversation & The Ouchkit: Couples Therapy in a Box by Betsy Sansby MS LMFT • Interpersonal Effectiveness Skills: DEARMAN GIVE & FAST by Dr. Marsha Linehan • The Peaceful Heart: A practical guide to unconditional love and forgiveness by Mary Hayes-Grieco

32. Ethics & Law Universal Ethics • Beneficence • Non-malefalence • Preserving Independence • Fidelity or True to Purpose • Justice Legal • Informed consent • Confidentiality

33. Summary & Application • Biopsychosocial model & Addiction dynamics in early recovery • Strategic role of the clinician as guiding interpersonal problem solving • Basic paper & pencil or related activities for identifying, stimulating & potentially resolving interpersonal issues • Review of handouts & bibliography • Applied exercise(s)