Family Therapy for Treating Major Depression Research Paper

Introduction

Cognitive-behavioral therapy is one of the recent approaches to depression treatment. While depression should not be diagnosed in the absence of depressed mood, in some patients the depressed mood is either well hidden or expressed only in derivative form as attitudinal, behavioral/acting-out, existential, and/or physical mood equivalents. Behavioral mood equivalents are not only a way to express but a way to relieve depression.

Depression Defined

Depression is a term used both too widely and too narrowly. Clinicians who use it too widely apply it to diverse normal states, like sadness and grief, and diverse abnormal states, like paranoid paralysis due to fear, schizoid remoteness, schizophrenic anhedonia, and obsessive ambivalent paralysis. Some clinicians overapply the concept for neurotic reasons, perhaps because their own depression has colored their world in its depressive image. Others overapply the concept for practical, nonneurotic masons: they run a depression clinic, have a research grant, or are caught up in a wave of popular sentiment (Alexopoulos et al 2000).

Every depression is created and sustained by vicious cycles. One depressive’s anger drove nonmasochistic people away. A person can feel lonely and abandoned, he can be angry over being abandoned, and his anger drove more people away. As an example of different legs to disable and different ways to disable each leg, the angry leg in the case cited above can be disabled with, among other things, abreaction, drugs, or shock (not necessarily recommended); and/or the abandonment leg can be disabled with, among other things, socialization groups or interpersonal analysis. In each case the results can be the same: no anger, no loneliness, no depression.

A good eclectic practitioner not only combines treatment approaches but varies each according to a specific need. He might use a combination of antidepressants and psychotherapy for both reactive and endogenous depression (Gurman & Jacobson 2002). This obvious statement must be made, because some clinicians rigidly believe that one should use psychotherapy for the first, drugs for the second. In the reactive depression, the practitioner might give the antidepressant in a lower dose, to promote relaxation and sleep and in psychotherapy emphasize understanding, while in the endogenous depression he might give the antidepressant in a higher dose, to elevate mood and in psychotherapy emphasize support (Alexopoulos et al 2000).

Cognitive-Behavioral Therapy and Family

Most explanations of family have concentrated on the formal nature of the relations between family members. These relations are ones that are either biologically created or married. Family is defined as “a fundamental social group in society consisting especially of a man and woman and their offspring; a group of persons sharing a common ancestry; lineage; or all the members of a household under one roof” (p. 488).

The Cognitive-behavioral therapy model proposes that individuals’ thoughts, feelings, and behaviors in the family setting can be understood in terms of the cognitions that they hold in their family structure. The cognitions in a person’s family structure include those that detail his or her understanding of the family rules, what he or she expects to give to and get from family relationships, and how healthy families operate.

The Cognitive-behavioral therapy model further proposes that individuals building a romantic relationship draw from their respective family schemas and, without being aware of doing so, create rules to govern their interactions. These rules, as a group, are called the family constitution. One useful way to understand the family constitution is to think of it as a tool that enables psychologically connected individuals to live together and meet their needs in an orderly, rule-directed way that makes household life predictable and stress levels tolerable (Beck 1986).

According to cognitive-behavioral therapy in depression treatment individuals would be taught lessons like these in adolescence, before they begin forming romantic relationships. Instead, in the absence of institutionalized instruction in family life in the public schools, by the time family members recognize that they have a serious family problem and need treatment, they face a challenge that is like an onion, with many issues layered upon the central difficulty.

At this point, as much as they might want to solve their own problems without help, they cannot. One reason why this is so is that, given the onion-layered nature of their problems, family members, individually or as a group, lack the ability to “diagnose” the difficulties they face and to identify their underlying causes. Moreover, they lack the skill necessary to determine the kinds of adjustments that would lead them to overcome what they are facing.

Given this situation, cognitive-behavioral family is oriented toward helping family members both solve the problem at hand and learn about family life so they can limit the disruptiveness of problems they face in the future (Beck 1986). Toward these ends, cognitive-behavioral therapy includes educational components during which practitioners teach individuals the cognitive-behavioral model, which provides a common language and a theory to guide them, and self — help techniques they can use to diagnose and intervene in future family problems. Before exploring cognitive-behavioral therapy in more detail, a brief sketch is given to place this method in a historical perspective (Bemporad 1989).

During all stages, cognitive-behavioral therapy practitioners maintain a health-promoting atmosphere, proceeding in a planned way, modeling effective behavior, and explaining the purposes of their comments (cognitive mediation) as sessions unfold. They support individuals by pointing out the inevitability of conflict in family life and the universality of the struggle to find workable solutions to the complex difficulties human beings face as they try to live together in harmony (Beck et al 1979).

And, last but not least, practitioners explain that people in therapy are usually concerned about being criticized, embarrassed, or singled out as the cause of family problems. However, in cognitive-behavioral therapy no blame is leveled at individuals; the focus is on the family system and the theme is cooperative, mutually supportive problem-solving. Those involved, including the practitioners, will fail together as a team or, more likely, succeed together to the family’s benefit (Baucom & Epstein 1990).

While conducting first-session business (acknowledging presenting problems, rapport building, collecting relevant history, discussing office policies, etc.), practitioners introduce the treatment goal of teaching individuals to understand themselves and their family dynamics in new ways — ways that will foster behavioral changes, more family joy, and fewer heartaches. Individuals are told that they will be taught the cognitive-behavioral therapy model and once they acquire a working knowledge of it, they will have a tool to use to better understand themselves and what is occurring in their family system (Beck et al 1979).

In addition, the model will provide them with a common vocabulary and way of understanding family life, both of which they will share with their practitioner. Empowered in this way, they will be more effective in solving the problems they face. In depressives the excessive anger is often kept inside.

Guilt is the usual reason cited, but the anger might also be stifled and introjected because the object is someone needed; someone who has already suffered too much, as with someone physically ill or dying; or someone with a good excuse, as with someone mentally ill. Again, the anger might be stifled because, as with natural disasters, there is no one, except perhaps God, who can be held responsible, and getting angry with fate or God is too nebulous and too unfocused to seem appropriate or helpful, or because, as with just wars, them is no one who can be blamed (Beck et al 1979).

Cognitive-behavioral therapy practitioners use “the healthy family member” and “the healthy family unit” as anchor points to guide them in the assessment process. For instance, they know that healthy family members hold cognitions that support other family members and themselves in seeking and achieving individual fulfillment and cognitions that help family members live in harmony. Cognitive-behavioral therapy practitioners can compare individual family members’ cognitions to these anchor points. When the practitioner and individuals make an assessment that these cognitions lead to counterproductive, nonsupportive, and unhealthy behaviors, they can develop a plan or intervention to deal with the issue (Dattillo & Padesky 1990).

In making assessments, practitioners usually focus on the functions of family members’ cognitions rather than their content. Consider assessments of family constitutions, for example. The content of the rules in family constitutions and the nature of the structure they provide vary greatly in healthy family units, reflecting individuals’ unique personalities, values, backgrounds, and goals. However, all health-promoting family constitutions serve the same functions (Dattillo & Padesky 1990).

That is, the structure family life so that family members can serve the social functions society expects, interact among themselves in ways they find satisfactory, and function effectively in achieving goals and in meeting the ever-changing challenges they encounter individually and as a unit. Besides focusing on the process by which the family unit moves toward its goals, practitioners and individuals also assess how family members address the interpersonal problems they inevitably face.

Using discussions of past or recurrent conflicts, deduction, and whatever means work, family members consider what cognitions cause them problems and also identify the cognitions they hold regarding problem-solving in the family setting. As a result of these explorations they typically look at the rules in their family constitution about problems and problem solving, and how the constitution might be edited to help them deal more effectively with persistent interpersonal conflicts (Epstein et al 1988).

Cultural and ethical considerations involve confidentiality issues and privacy concerns. Because unique ethical issues arise in implementing family therapy, researchers suggest that family practitioners continue to develop ethical standards for their professional activities. As soon as new and amended rules enter the family constitution, they acquire their own “power,” directing individuals’ behaviors and, concomitantly, influencing their perceptions, thoughts, information-processing mechanisms, and feelings (Epstein et al 1988). Sometimes individuals are helped greatly by the process of identifying their costs and benefits clearly enough that they can be evaluated.

Practitioners can use personally prepared videotapes or popular television shows to familiarize individuals with the c/b concept. For example, using directions provided by practitioners, individuals can watch programs and list the costs and benefits each character experiences from family membership. Next, he had them list on a poster all the tasks and family roles that had to be completed in their household. Then, guided by the practitioner and inspired by the film, the family members prepared a written agreement about what chores were, should be, and would be assigned to whom.

The parents accepted the plan and, because the children had a sense of ownership for it, the plan worked and the chores were done. In sum, during this step, practitioners teach individuals how to analyze their cognitions and relationships and to develop the habit of frequently doing so (Beck et al 1979). They get better in touch with the impact that their own cognitions have on them, they learn to appreciate that each family member has cognitions and that these effect them, and they learn to identify and examine the dynamics they experience in their relationships in the family system (Goldenberg & Goldenberg 2004).

By this point in treatment, family members better understand the difficulties in solving their problems and have probably made progress in addressing them. However, in Step 5, the rate of progress accelerates substantially. The focus in Cognitive-behavioral therapy turns to promoting behavioral change in individuals which, in turn, causes change in the family system. At this step, cognitive-behavioral therapy practitioners, who are eclectic, sense which treatment approaches would most likely enable family members to modify their cognitions and behaviors (Beck et al 1979).

They draw interventions from all literature as well as developing their own, when necessary. For example, they use family therapy interventions, such as reframing, paradoxical directives, and sculpting; cognitive-behavioral therapy interventions, such as role-playing, behavioral rehearsal, modeling, in vivo assignments, communication training, and problem-solving skills development (Gurman & Jacobson 2002).

Whenever possible, practitioners select interventions that help individuals change their behavior and, at the same time, benefit them over the long run by bringing to light important family-related cognitions. For example, practitioners may prescribe regularly scheduled family meetings. These have particular value if, first, individuals use them to discuss and find solutions to problems they are experiencing at the moment in the household and if, second, individuals use them to identify and alter (or replace) family constitution rules that have been fostering the difficulties (Holahan and Moos 1991).

Practitioners ask individuals to list a few activities they would like each of the other family members to perform more frequently. Family members benefit in at least two ways from making such lists and from trying to meet each others’ requests: They very concretely become aware of what are benefits in each other’s c/b ratios while, at the same time, they improve each other’s c/b ratios by providing more of what they seek in family life (Holahan and Moos 1991).

Practitioners may build further on this intervention, seeking to change the rules in the family constitution by asking individuals to set contingencies (reinforcement or punishment) for appropriate behavior (e.g., a child cleaning her room, following a studying schedule on school nights, eating healthy meals) or to use behavioral contracts (Gurman & Jacobson 2002).

Patients who are excessively/inappropriately angry should first take steps to reduce their anger, such as removal. If that cannot be done they might consider expressing the anger, but in modified form, following the principle that when it comes to expressing anger, refined is better than raw. Some good ways of refining anger are positive sublimation, deflection, reaction formation, and intellectualization (Hollon et al 1991).

If modified expression seems inadequate to provide relief and/or does not have the desired effect, then the patient might be told to have a temper tantrum and get it over with. But he can only have one when the following conditions are all met:

1. it is safe, constructive, and creative to do so;
2. the anger is justified;
3. the anger is directed to the source of the anger, not to an innocent substitute;
4. the original purpose of the anger remains the focus of the anger throughout;
5. the target can defend himself without becoming unduly anxious and depressed; and
6. the target’s basic feelings will not change from positive to negative in a way that eventually proves detrimental to the patient (Hollon et al 1991).

Because it is impossible to know in advance how much anger is too much, ideally the patient should judge the effect of the anger while he is expressing it and adjust the level of his expression accordingly. For this reason, in the beginning he should always leave a margin of error that allows him to back off, if at some point he recognizes he has gone too far. Finally, for some depressives one might suggest the unthinkable–suppressing excessive/inappropriate anger. Further, they represent a host of other difficulties that will unfold in their home in the future, unless the family makes changes (Beck 1986).

Therefore, practitioners explain, while family members seek to address the problem at hand, they are also acquiring information and skills to help them avoid certain difficulties in the future (and to better manage those that do develop). Practitioners help individuals address the problem at hand, understand why it evolved, and deal with what happened as it unfolded, by applying concepts from the cognitive-behavioral therapy model.

Using these, individuals work to analyze the situation and to plan effective ways of dealing with it. Usually they reach an agreement about what the nature of the difference is and then they try to identify which cognitions in each individual are playing roles in causing and maintaining the problem. If the problem at hand has been a recurrent one or represents a family of problems the individuals have faced, and after they have some success in diagnosing and developing a plan to attack it, the practitioner may be able to move the discussion to a higher conceptual level and make these points (Beck 1986).

Because the problem at hand (or the type of problem it represents) has recurred over time, there must be some factor responsible for its emerging over and over again and, there must be some obstacle that has in the past blocked family members’ efforts to solve it. The practitioner then congratulates the individuals for perhaps “cracking the nut” and mobilizing themselves to attack and find a solution to what has been a recurrent and elusive family problem.

After considering questions like these, family members can make informed decisions about model usage. If they decide to continue with their models, after the discussions they will undoubtedly feel less driven by and more comfortable with engaging in model-prescribed behaviors. Often, however, they find other ways to handle the issues from which models had been protecting them. Finally, cognitive-behavioral therapy practitioners may want to again address the issue of communication and how family members can solve, or better yet, avoid common problems (Beck 1986). However, there are probably more subtle forms of resistance than obvious ones.

More disguised versions include instances in which verbally able individuals continually steer discussion during cognitive-behavioral therapy sessions toward surface-level considerations. More specifically, after repeated encouragement to do otherwise, they continually return to talk about the here and now, working toward resolving a problem at hand and only that. Their desire to address the problem at hand makes sense, because it is causing distress. However, they resist going beyond this concrete level toward deeper thinking: considering the present issue as one example of a class of problem-causing issues (Beck et al 1979).

Conclusion

In sum, cognitive-behavioral therapy is one of the most effective approaches which help to treat depression in families. During cognitive-behavioral therapy, people will raise problems for discussion that occur between sessions in their day-to-day home life. Although attending to these as important issues in and of themselves, practitioners also explain that these daily problems have another kind of significance; that is, they represent the kinds of difficulties the family is prone to because of the nature of the cognitions members hold.

References

1. Alexopoulos GS, Meyers BS, Young RC, Kalayam B, Kakuma T, Gabrielle M, Sirey J, Hull J. (2000). Executive dysfunction and long-term outcomes of geriatric depression. Arch Gen Psychiatry 57(3), pp. 285-290.
2. Beck A. T. (1986). Cognitive Therapy and the Emotional Disorders. New York: International Universities Press.
3. Bemporad J. R. (1989). “Mood disorders: Intensive psychotherapy and psychoanalysis”. In American Psychiatric Association, Treatments of Psychiatric Disorders: A Task Force Report of the American Psychiatric Association. Washington, D.C.: American Psychiatric Association.
4. Baucom D. H., & Epstein N. (1990). Cognitive-behavioral marital therapy. New York: Brunner/Mazel.
5. Beck A. T., Rush A. J., Shaw B. F., & Emery G. ( 1979). Cognitive therapy of depression. New York: Guilford.
6. Dattillo F. M., & Padesky C. A. (1990). Cognitive therapy with couples. Sarasota, FL: Professional Resource Exchange.
7. Epstein N. B., Schlesinger S., & Dryden W. (1988). Cognitive-behavioral therapy with families. New York: Brunner/Mazel.
8. Goldenberg, I., & Goldenberg, H. (2004). Family therapy: An overview. (6th ed.). Pacific Grove, CA: Brooks/Cole.
9. Gurman, A. S., & Jacobson, N. S.(Eds.) (2002). Clinical handbook of couple therapy. (3rd ed.). NewYork: Guilford Press.
10. Holahan Charles J., and Rudolf H. Moos. (1991). “Life stressors, personal and social resources, and depression: A 4-year structural model”. Journal of Abnormal Psychology, 100 (1), pp. 31-38.
11. Hollon Steven D., Richard C. Shelton, and Peter T. Loosen. (1991). “Cognitive therapy and pharmacotherapy for depression”. Journal of Consulting and Clinical Psychology 59 (1), pp. 88-99.