Counseling Adults who have Bipolar Disorders Practice Brief

Published September 2016


Victoria Kress, Walden University and Youngstown State University
Stephane Sedall, Youngstown State University
Matthew Paylo, Youngstown State University


The bipolar disorders are characterized by dramatic changes  in mood, activity, and/or  energy levels that significantly affect one’s functioning (NIMH, 2016). Those who have  these disorders  may dis- play mixed episodes in which they demonstrate characteristics of both mania and depression. Manic or hypomanic episodes (up states that do not meet the criteria  for mania) are characterized by periods of elevated mood and high-energy, while  depressive episodes are characterized by periods of low mood and energy (APA, 2013; NIMH, 2016).

Estimates  suggest that  in the United  States,  2.6% of the adult  population  has one of the bipolar disorders  (NIMH, n.d). An equal number  of men and women  develop  bipolar  disorder  although, research  findings  support women  have more depressive, mixed episodes, and experience rapid cy- cling more often than men (American  Psychiatric Association [APA], 2013).

Counselors can diagnose bipolar  1, bipolar  11, cyclothymia, and for clients who do not meet the cri- teria for these more traditional bipolar  disorder  diagnoses, counselors  might designate a diagnosis of other specified and unspecified related disorders (NIMH, 2016). Ultra-rapid cycling is a possible  feature  of bipolar disorders which involves multiple mood episodes within one week or even a single day. Rapid cycling is more common in women than men, and it may be caused by an interaction between  bipolar disorder  and substance abuse, triggered by the use of antidepressants, or associated thyroid  disease (White & Preston, 2009). To be diagnosed with the various  bipolar  disorders,  different  combinations of symptoms and frequency of symptoms must be present. Additional detail on the symptom  patterns associated with the various  bipolar disorders can be found in the DSM-5 (APA, 2013).

Resources:
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author. National  Institute  of Mental  Health. (n.d). Bipolar disorder among adults. Retrieved from: http://www.nimh.nih.gov/health/statistics/prevalence/bipolar-disorder-among-adults.shtml

National  Institute  of Mental  Health.  (2016). Bipolar disorder. Retrieved from:http://www.nimh.nih.gov/health/topics/bipolar-disorder/index.shtml

IDENTIFICATION/ASSESSMENT STRATEGIES


Many  disorders  are comorbid  with  a bipolar  disorder  diagnosis including attention-deficit/hyper- activity disorder  (ADHD), substance use disorders,  and anxiety disorders.  The following section includes several  screening measures  that may be helpful in identifying bipolar disorders.
 
Mood Disorder Questionnaire
The Mood Disorder  Questionnaire (MDQ; Hirschfeld  et al., 2000) is a brief self-report  screening measure  that is used to help identify  individuals who have  bipolar  disorders.  The MDQ has both sensitivity and specificity, and it consists of 13 questions plus items assessing clustering of symptoms and functional impairment. If the patient answers  “yes” to seven or more of the 13 items in question
1, and “yes”  or “moderate” or “serious”  to question  3, this is considered a positive screen, and the possibility of disorders should be examined more closely.  The questionnaire takes 5 minutes or less to complete.

A pdf of the MDQ screen is available to view  at:http://www.drdianenguyen.com/images/Bipolar_screen.pdf

Composite International Diagnostic Interview: Bipolar Disorders Screening Scale
The Composite  International Diagnostic Interview (CIDI;  Kessler  et al., 2006) is a structured  interview assessment. The CIDI consists  of 12 questions  including two stem questions,  one question related  to criterion  B symptoms (from the DSM-5) screening, and nine questions  directly related to criterion  B symptoms. The more questions  answered in a positive,  affirming way  the greater  the likelihood  of a positive diagnosis. The scoring  is as follows: nine questions  with positive affirmation is very-high risk, 7-8 questions  with positive affirmation is high risk, six questions  with positive affir- mation  is moderate  risk, five questions  with  positive affirmation is low risk, and 0-4 questions  with affirmation is very  low-risk.  The interview takes five minutes or less to complete.

A pdf of the CIDI screen is available to view  at: http://www.cqaimh.org/pdf/tool_cidi.pdf

The General Behavior Inventory
The General  Behavior  Inventory (GBI; Depue et al., 1981) is a self-screened measure  designed  to assess the severity of the core symptoms of bipolar disorders over the past year. The full 73 item ver- sion has demonstrated internal  consistency and reliability as well as sensitivity to detecting bipolar disorders.  The measure  is reported  on a 4-point  rating  scale and is easily  administered in a clinical setting.

A pdf of this inventory is available to view  at:https://cls.unc.edu/files/2014/06/GBI_self_English_v1a.pdf

Structured Clinical Interview for DSM-5
The Structured  Clinical Interview (SCID; Spitzer, Williams,  Gibbon,  & First, 1992) is a clinical  in- terview first designed  to be used as a part of the intake process. Over the years,  it has become  one of the most common assessment measures used to diagnose bipolar disorders in adults, in particular bipolar 1 disorder (Miller, Johnson, & Eisner, 2009). The SCID is a semi-structured interview that is broken up into different modules to cover different diagnoses; its bipolar module has demonstrated appropriate interrater  reliability (Miller et al., 2009).

To view  more information and/or  to purchase  the SCID-5 visit:https://www.appi.org/products/structured-clinical-interview-for-dsm-5-scid-5
 
INTERVENTION/TREATMENT STRATEGIES

Psychoharmacotherapy
Because the bipolar  disorders are caused by a complex set of biological and genetic  factors, medica- tion should always be used to treat those who receive  the diagnosis. In fact, most people who have bipolar disorder will need to take medication throughout their lives to manage the symptoms of their illness. Medication compliance is an important treatment goal when counseling those who have bipo- lar disorder. However, many bipolar medications involve short and long term side effects (i.e., weight gain,  nausea,  sleep and appetite  changes; NIMH, 2016) that may  cause  clients  to stop prematurely their medications.

There are strategies that the client  and the counselor  can use to facilitate medication compliance. For example, counselors may work together  with the client to help set up electronic tools for period- ic reminders.  They may also help the client set up a medication log that can help keep track of the medications, side effects, and other substances that may interfere  with the medications.

When prescribing medications, physicians first consider  what  level  of intervention a client  needs. These phases  include:  the acute phase, during  which  the goal  is to control  the most severe  symp- toms of the manic,  mixed,  or depressive disorder;  the stabilization phase,  during  which  the goal is full recovery from the acute  phase,  and the treatment of residual  symptoms and psycho-social impairment; and lastly, the maintenance phase, during which the goal is to prevent  recurrences and continue  treating residual  symptoms (Barlow, 2008).

Mood stabilizers, such as lithium and valproic acid (e.g., Depakote), are the most common medica- tions used to treat those who have  bipolar  disorders  (National  Institute  of Mental  Health [NIMH];
2016). Lithium is effective in addressing both mania and mixed states and it can significantly decrease the severity and frequency of mood swings  (Atkins, 2007; NIMH, 2016). Valproic acid (e.g., Depa- kote) is an anticonvulsant medication used as a mood stabilizer to treat adults  who have  “mixed” symptoms of mania and depression  and rapid cycling (NIMH, 2016).  Lamotrigine (e.g., Lamictal; Atkins,  2007), an anticonvulsant used to treat  symptoms of bipolar,  is recommended for the pre- vention  of acute mania and depressive episodes associated with bipolar 1, and it is sometimes  used in combination with Lithium (VA/DoD, 2010). Other anticonvulsants such as, carbamazepine (e.g., Tegretol)  and oxcarbazepine (e.g., Trileptal),  are commonly used to treat seizures  and neuropathic pain, but can also be used to treat symptoms of bipolar disorder  (VA/DoD, 2010).

Antipsychotic medications are also often used to stabilize  mood and to treat those who have  bipolar disorders. Lurasidone  (e.g., Latuda), a newer medication, is used to treat adults who have bipolar disor- ders and it can be taken alone or with a medication such as lithium or valproic acid (Franklin, Zorowitz, Corse, Widge, & Deckersbach, 2015). Aripiprazole (e.g., Abilify), an antipsychotic, is used to treat adults who have  acute manic  or mixed  episodes  associated with  bipolar  1 (Barlow, 2008). It can be used by itself or taken with  lithium  or valproic acid. Cariprazine (e.g., Vraylar) was recently approved by the FDA to treat bipolar 1 disorder in adults. Trials have demonstrated its efficiency in treating acute manic or mixed episodes associated with bipolar 1 (Durgam et al., 2015; McCormack, 2015).

Antidepressants are often used to treat those who have  bipolar  disorders.  However, it can take up to 4-6 weeks for an anti-depressant to have a full effect. As such, physicians often need to try several medications before finding  what  works best for a patient  (Harmer, Goodwin,  & Cowen,  2009). An- tidepressant medications often used in conjunction with other mood stabilizing medications include SSRIs (selective serotonin  reuptake  inhibitors; e.g., Zoloft, Prozac) and SNRIs (i.e., selective sero-
 
tonin and norepinephrine reuptake inhibitors; e.g., Effexor, Wellbutrin;  Atkins, 2007; Barlow 2008). It is important to note that antidepressants may lead to worsened rapid cycling and may stimulate hypomanic/manic episodes in adults who have bipolar disorders (Atkins, 2007; Barlow, 2008).

Resources:
For more information: http://www.bphope.com/blog/when-taking-bipolar-medications-becomes-overwhelming/
http://www.bphope.com/sticking-with-it/

Interpersonal and Social Rhythm Therapy
Interpersonal and social rhythm  therapy  (IPSRT; Frank, 2005; Hlastala,  Kotler, McClellan, & Mc- Cauley, 2010) is an evidence-based treatment approach  that can help with regulating biological and social rhythms  (i.e., sleeping, eating,  socializing, and exercise  patterns).  The goal of this approach  is to help clients identify  the disruptions that already exist in their daily  routine (i.e., sleep) as well as make the connection between  daily  routine/ rhythm  disruptions and mood destabilizations, which can escalate  symptoms if not properly managed. IPSRT helps recognize interpersonal conflicts that are disrupting daily  routine  and making  symptoms associated with  bipolar  worse.  This approach emphasizes techniques that can be used to help manage stressful life events, strategies for enhancing and managing social supports and relationships, and it aims to reduce disruptions in social rhythms. The counselor and the client may work together  to develop  a daily schedule focused on diminishing the conflicts and disruptions caused by the disorder.

Studies have concluded  that sleep is vital in regulating bipolar disorder and irregular sleep routines can have a negative impact  on those who have bipolar disorder, even between  mood episodes (Ng et al., 2016). Disturbed  sleep, or a lack of sleep even  when  not experiencing mood symptoms, has been correlated with  irregular social  rhythms  (Ng et al., 2016). For those who have  bipolar  disor- ders, a lack of sleep can increase  insomnia,  therefore  triggering a mood episode.  In addition,  dis- turbed sleep can incite  depressive episodes  (Ng et al., 2016). Counselors can have  clients  monitor the number of hours they sleep so that they can recognize patterns,  shifts in sleep patterns,  and how these relate to their mood and energy states. A regular,  consistent sleep-wake schedule  is essential in preventing and triggering symptoms of bipolar disorder.

Resources:
A downloadable pdf of a sleep log can be found at: http://yoursleep.aasmnet.org/pdf/sleepdiary.pdf

For more information:
http://www.bphope.com/blog/five-tips-for-better-sleep/
http://www.bphope.com/hope-harmony-headlines-bipolar-sleep-problems-and-solutions/
http://www.bphope.com/poor-sleep-predicts-mood-recurrence-in-remitted-bipolar-2/
http://www.huffingtonpost.com/wendy-k-williamson/sleep-the-other-half-of-bipolar-medica-tion_b_7985708.html?ir=Healthy%20Living?
http://www.bphope.com/sleep-irregularities-impact-more-than-just-mood/
 
Cognitive Behavioral Therapy
When combined  with  psychopharmacological intervention, cognitive behavioral therapy  (CBT) is an evidence-based approach  for treating bipolar  disorders.  CBT involves identifying distorted thoughts and helping  clients to learn how to control, manage,  and change  these thoughts (Driessen
& Hollon, 2010). CBT is founded on the assumption that mood, thinking, and behavior all influence each other. Therefore,  in treating adults  who have  bipolar  disorders,  the first step is to determine the  problem  such  as identifying the  rapid  - distorted  thoughts and  behaviors and  the  emotions associated with  them.  CBT also focuses  on communication, problem-solving skills,  and teaching clients  the skills  required  to cope with  symptoms and the disruption  of routines  (i.e., sleep,  diet, social  interactions) that trigger  bipolar  episodes.  Instability of circadian rhythms  and impairment of the motivational/reward system  in the brain (i.e., goal attainment) are important factors that are affected  by bipolar  disorder.  Furthermore, applying self-regulation skills, promoting a routine  and schedule,  and challenging thoughts and behaviors can help reduce symptoms.

Studies  have  demonstrated that  CBT reduces  the frequency of bipolar  episodes,  enhances  social functioning, and stabilizes mood (Driessen  & Hollon,  2010;  Lam et al., 2003). Studies  have  also demonstrated that combining CBT with medication can reduce the risk of bipolar relapse and result in fewer  manic  episodes  as compared  to medication alone (Lam et al., 2003; Salcedo  et al., 2016; Watkins, 2003).

Mindfulness-based cognitive  therapy   (MBCT;  Segal,  Williams,  &  Teasdale,  2002)  was  recently adapted  for the treatment of bipolar  disorder  and shows  promise as an effective  intervention. This mindfulness-based approach  was designed  to prevent  relapse in patients  who have recurring major depressive episodes (Segal et al., 2002). MBCT combines the use of traditional CBT techniques (i.e., thought  and feeling connection) and mindfulness practice  (i.e., meditation, self-observation) to help clients become more aware of their thoughts and feelings through focusing their attention and being present.  Research examining the effectiveness of MBCT has demonstrated decreases  in relapse of depression  by 43% and decreases  in anxiety over time (Miklowitz et al., 2009; Stange  et al., 2011; Williams et al., 2014).

Resources:
More information on MBCT can be found at: http://mbct.com/
http://mbct.com/wp-content/uploads/Mindful-Future-of-Therapy-08_2016.pdf

Family-Focused Therapy
Family-focused therapy  (FFT; Miklowitz & Goldstein,  1997) is an evidence based  family  therapy approach  that involves the client and family  members  developing skills related to family  communi- cation  and problem  solving, as well as diminishing family  conflict.  Social support plays  an import- ant role in managing bipolar disorder, and thus a strong family  structure is crucial.  Family  structure helps  promote  stable,  consistent routines  (i.e., sleep  schedule,  eating  habits,  medication manage- ment; Reinares,  Bonnin, Hidalgo-Mazzei, Moreno-Sanchez, & Vieta, 2016). FFT involves providing psychoeducation to both the client and family  about illness-management strategies, relapse preven- tion, and adherence  to pharmacotherapy. It also involves enhancing the family’s  knowledge about the symptoms of bipolar disorder  and how to handle these symptoms (Miklowitz, 2006).

FFT applies  a biopsychosocial framework to encourage balance  within  the social  and family  en- vironment (Miklowitz & Goldstein,  1997).  The term  expressed  emotion is used  to describe  hostile
and critical  attitudes  that the family  members  may have  towards each other (Reinares  et al., 2016). Counselors work  with  the client  and family  members  to help  facilitate an awareness of expressed emotion and adaptive strategies that can be used to best facilitate family  communication. Treatment typically consists  of 21 sessions  over the course of 9 months  (Miklowitz et al., 2004). Studies  have demonstrated a decrease in depressive symptoms and expressed emotion among families, as well as an increase  in positive communication between  family  members  when FFT is applied (Rivas-Vazquez, Johnson, Rey, & Blais, 2002). FFT has been shown to improve  the clients’ level of social adjustment and perceptions of relationship functioning (Rivas-Vazquez et al., 2002).

Resources:
http://gracepointwellness.org/4-bipolar-disorder/article/11221-bipolar-disorder-treatment-family-focused-therapy-and-interpersonal-social-rhythm-therapy


REFERENCES
Adkins,  C. (2007).  The bipolar disorder answer book: Professional  answers to more than 275 top questions. Naperville, IL: Sourcebooks

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th  ed.). Washington, DC: Author.

Barlow,  D. H. (2008). Clinical handbook of psychological disorders: A step-by-step treatment manual (4th   ed). New York, NY: Guilford.

Depue, R. A., Slater,  J. F., Wolfstetter-Kausch, H., Klein, D., Goplerud,  E., & Farr, D. (1981). A behavioral paradigm for identifying persons at risk for bipolar  depressive disorder:  A conceptual framework and five validation studies. Journal of Abnormal  Psychology, 90, 381–437.

Driessen, E., & Hollon, S. D. (2010). Cognitive behavioral therapy  for mood disorders:  Efficacy, moderators and medi- ators. Psychiatric Clinics of North America, 33, 537–555.

Frank, E. (2005). Two-year outcome for interpersonal and social rhythm  therapy  in individuals with bipolar 1 disorder. Archives of General Psychiatry, 62, 996–1004.

Franklin,  R., Zorowitz,  S., Corse, A. K., Widge, A. S., & Deckersbach, T. (2015). Lurasidone  for the treatment of bipolar depression: An evidence-based review. Neuropsychiatric Disease and Treatment, 11, 2143–2152.

Harmer, C. J., Goodwin,  G. M., & Cowen,  P. J. (2009). Why do antidepressants take so long to work? A cognitive neu- ropsychological model of antidepressant drug action. The British Journal of Psychiatry, 195, 102–108.

Hirschfeld,  R., Williams,  J. B.W., Robert  L. S., Calabrese, J. R., Flynn,  L., Keck, P. E. Jr., … Zajecka,  J. (2000). Devel- opment  and validation of a screening instrument  for bipolar  spectrum  disorder:  The mood disorder  questionnaire. American Journal of Psychiatry, 157, 1873–1875.

Hlastala,  S., Kotler, S., McClellan, M., & McCauley, A. (2010). Interpersonal and social rhythm therapy for adolescents with bipolar disorder:  Treatment  development and results from an open trial. Depression and Anxiety, 27, 457–464.

Kessler, R. C., Akiskal, H. S., Angst,  J., Guyer, M., Hirschfeld,  R., Merikangas, K. R., …Stang, P. E. (2006). Validity of the assessment of bipolar spectrum  disorders in the WHO CIDI 3.0. Journal of Affective Disorders, 96, 259–269.

Lam, D. H., Watkins, E. R., Hayward P., Bright, J., Wright, K., Kerr, N., …Sham, P. (2003). A randomized controlled study  of cognitive therapy  for relapse  prevention for bipolar  affective disorder.  Archives of General Psychiatry, 60,
145–152.

McCormack, P. L. (2015). Cariprazine: First global  approval. Drugs, 76, 2035-2043.

Miklowitz, D. J., & Goldstein,  M. J. (1997). Bipolar disorder: A family-focused treatment approach. New York, NY: Guilford.

Miklowitz, D., Axelson,  D., Birmaher,  B., George,  E., Taylor,  D., Schneck,  C., . . . Brent, D.(2004). Family-focused treatment for adolescents with bipolar disorder:  Results of a 2-year  randomized trial. Journal of Affective Disorder, 82, 113–128.

Miklowitz, D. (2006). A review of evidence-based psychosocial interventions for bipolar  disorder. Journal of Clinical Psychiatry, 67, 28–33.

Miklowitz, D. Alatiq,  Y., Goodwin,  G., Geddes,  J., Dimidjian, S., Hauser, M., …Williams, M. (2009). A pilot study  of mindfulness-based cognitive therapy  for bipolar disorder.  International Journal of Cognitive Therapy, 4, 373–382.

Miller,  C. J., Johnson,  S. L., & Eisner,  L. (2009). Assessment tools for adult  bipolar  disorder.  Clinical Psychology, 16, 188–201.
 
National  Institute  of Mental  Health.  (n.d). Bipolar Disorder Among Adults. Retrieved from: http://www.nimh.nih.gov/health/statistics/prevalence/bipolar-disorder-among-adults.shtml

National  Institute  of Mental  Health.  (2016). Bipolar Disorder. Retrieved from: http://www.nimh.nih.gov/health/topics/bipolar-disorder/index.shtml

Ng, T. H., Chung,  K. F., Ng, T. K., Lee, C. T., & Chan, M. S. (2016). Correlates and prognostic relevance of sleep irreg- ularity  in inter-episode bipolar disorder.  Comprehensive Psychiatry, 69, 155–162.

Reinares,  M., Bonnin, C. M., Hidalgo-Mazzei, D., Moreno-Sanchez, F., & Vieta,  C. E. (2016). The role of family  inter- ventions  in bipolar disorder:  A systematic review. Clinical  Psychology Review,  43, 47–57.

Rivas-Vazquez, R. A., Johnson, S. L., Rey, G. J., & Blais, M. A. (2002). Current treatments for bipolar disorder: A review and update for psychologists. Professional Psychology: Research and Practice, 33, 212–223.

Salcedo,  S., Gold, A. K., Sheikh, S., Marcus,  P. H., Nierenberg, A. A., Deckersbach, T., …& Sylvia, L. G. (2016). Em- pirically supported  psychosocial interventions for bipolar  disorder:  Current  state of the research.  Journal of Affective Disorders, 201, 203–214.

Segal Z. V., Williams J. M. G., & Teasdale J. D. (2002). Mindfulness-based cognitive therapy for depression: A new approach to preventing relapse. New York, NY: Guilford.

Spitzer, R. L., Williams, J. B. W., Gibbon, M. (1992). The structured  clinical  interview for DSM-III-R  (SCID). I: Histo- ry, rationale,  and description. Archives of General Psychiatry, 49, 624–629.

Stange,  J. P., Eisner, L. R., Hölzel, B. K., Peckham, A. D., Dougherty, D. D., Raunch,  S. L., …& Deckersbach, T. (2011). Mindfulness-based cognitive therapy  for bipolar  disorder:  Effects  on cognitive functioning. Journal of Psychiatric Practice, 17, 410–419.

Suresh D., Staracea, A., Dayong L., Migliorea, R.,  Ruthc, A., & Laszlovszky, I. (2015). The efficacy and tolerability of cariprazine in acute mania associated with bipolar I disorder:  A phase II trial. Bipolar Disorders, 17, 63–75.

The Department of Veteran Affairs (VA) & The Department of Defense (DoD). (2010, May). The clinical practice guideline for management of bipolar disorders in adults.

Watkins, E. (2003). Combining cognitive therapy  with  medication in bipolar  disorder.  Advances in Psychiatric Treatment, 9, 110–116.

Williams, M. G., Crane, C., Barnhofer, T., Brennan, K., Duggan, D. S., Fennell, M. J. V., …& Russell, I. T. (2014). Mind- fulness-based cognitive therapy  for preventing relapse  in recurrent  depression: A randomized dismantling trial. Journal of Consulting and Clinical  Psychology, 82, 275–286.

Published June 2015

Catherine  J. Brack and Greg BrackGeorgia State University

Couples with a trauma history are those in which one or both partners have a history of trauma -that is unrelated to combat since there is a separate literature on combat trauma- and has led to significant traumatic symptom displays. The trauma may have preceded or followed the couple formation. A traumatic event is defined by the DSM-5 (American Psychiatric Association [APA], 2013) as an actual or threatened death, serious injury, or sexual violence, or witnessing in person or learning indirectly that a close relative or close friend was exposed to violent, accidental, actual, or threatened death. About 8% of those who experience a trauma develop chronic PTSD (Kilpatrick, Resnick, & Milanak, 2013). Chronic PTSD is more persistent, difficult to treat, and impairing than acute PTSD (Norris & Slone, 2007). Survivors of a broad spectrum of traumas deal with difficulties with intimate relationships and often experience higher separation and divorce rates (Brown-Bowers, Fredman, Wanklyn, & Monson, 2012; Colman & Widom, 2004; Compton & Follette, 1998, 2002; Watson & Halford, 2010) and difficulties in forming intimate relationships with others (Alexander, 2008). Many couples with a trauma history seek couple therapy to address the effects of traumatic experiences on their relationship.

Resources:
Effects of Complex Trauma. The National Child Traumatic Stress Network. http://www.nctsn.org/trauma-types/complex-trauma/effects-of-complex-trauma

Trauma and Relationships. The International Society for Traumatic Stress Studies.
http://www.istss.org/AM/Template.cfm?Section=PublicEducationPamphlets&Template=/CM/ContentDisplay.cfm&ContentID=1465
 

IDENTIFICATION/ASSESSMENT STRATEGIES

One of the first tasks when working with couples is to determine if trauma is a component of the couple’s difficulties (see Basham & Miehls, 2004). This is not always easy, particularly when clients have childhood sexual abuse histories, and feel shameful and reluctant to disclose (Cobia, Sobansky, & Ingram, 2004). Zala (2012) stated, “Clients sometimes express dissatisfaction with couple therapists for not considering the impact of past childhood sexual assault” (p. 220). The client may not disclose such information or, even if disclosed, may not recognize that the trauma affects couple functioning. Thus, the counselor must determine how the traumatic history is affecting couple functioning, and how to address such issues without making the abuse survivor the “identified patient” and the designated “problem” within the couple (Compton & Follette, 1998, 2002). When asking about trauma history, it is important not to use the word abuse, because use of the word results in underreporting (Briere, 2004). Instead, behavioral descriptions of experiences can be used to better get at trauma and abuse histories.

Self-report instruments that assess for trauma include the Trauma Symptom Inventory (TSI) or Trauma Symptom Inventory - Alternate Form (TSI-A; Briere, 1995), Posttraumatic Stress Diagnostic Scale (PDS; Foa, 1995), Detailed Assessment of Posttraumatic Stress (DAPS; Briere, 2001), Cognitive Distortions Scale (CDS; Briere, 2000a), Inventory of Altered Self-Capacities (ISC; Briere, 2000b),Trauma and Attachment Belief Scale (TABS; Pearlman, 2003), Multiscale Dissociation Inventory (MDI; Briere, 2002), and Childhood Trauma Questionnaire (CTQ; Bernstein & Fink, 1998). Interviews that assess for trauma include the Structured Clinical Interview for DSM-IV (SCID-PTSD; First & Gibbon, 2004), Structured Interview for Disorders of Extreme Stress (SIDES; Pelcovitz et al., 1997), and Childhood Maltreatment Interview Schedule—Short Form (CMIS-SF; Briere, 1992). In addition to looking for a history of trauma in each partner, it is important to explore violence in the relationship (Alexander, 2008), since couples counseling should be discontinued if there is relationship violence (Basham & Miehls, 2004; Johnson, 2002). The Conflict Tactics Scale (CTS; Strauss, 1979) may be used to assess for the occurrence of violence in the relationship.

Assessing couple functioning can help determine the impact of trauma on couples and functioning can be assessed via self-report instruments such as the Dyadic Adjustment Scale (DAS-Revised; Busby, Christensen, Crane, & Larsen, 1995), RELATE (Busby, Holman, & Taniguchi, 2001) and Couples Satisfaction Index (CSI; Funk & Rogge, 2007).

Resources:
Collection of Assessment Resources. The International Society for Traumatic Stress Studies. http://www.istss.org/AssessmentResources/4435.htm

The Relate Institute. https://www.relate-institute.org/

 

INTERVENTION STRATEGIES

There are two empirically supported couple’s therapy approaches that have demonstrated efficacy when working with couples with histories of trauma: integrative behavioral couple therapy (IBCT; Compton & Follette, 1998; Jacobson & Christensen, 1998; Leonard, Follette & Compton, 2006; Wiedeman, 2011) and emotionally-focused couple therapy (EFCT; Johnson, 2002; Johnson & Courtois, 2009; Johnson & Greenberg, 1985; Johnson & Williams Keeler, 1998). These two empirically supported treatments are reviewed below. Several other approaches have been suggested for the treatment of couples with a history of trauma, but since these models are not based on empirically supported couple therapy approaches, they will not be discussed in further detail. These additional approaches include Basham and Miehls (2004) integrative model of couples with a trauma history; Buttenheim and Levendosky’s (1994) object relations model for child sexual abuse (CSA) couples with a trauma history; and Maltas’s (1996) psychoanalytic model for CSA couples with a trauma history.

Integrative Behavioral Couple Therapy (IBCT)
Compton and Follette (1998) discussed the limitations in effectiveness of traditional behavioral couple therapy for working with couples with issues of severe relationship stress (Baucom & Hoffman, 1986), emotional disengagement and conflict avoidance (Gottman & Krokoff, 1989; Hahlweg, Revenstorf & Schindler, 1984), or psychological difficulties in one partner (Jacobson, Fruzzetti, Dobson, Whisman, & Hops, 1993). Compton and Follette (1998) recommended the use of integrative behavioral couple therapy (IBCT; Jacobson & Christensen, 1998) which combines traditional behavioral couple therapy with acceptance therapy. Compton and Follette included a pretreatment stage in which safety issues, such as suicide, homicide, violence, child abuse or neglect, and other high risk behaviors, such as drinking and driving or those that are associated with the risk of HIV, are addressed. If safety issues do not exist, they recommended determining the couple’s commitment to the relationship and to counseling. The focus of IBCT with couples with a trauma history is to resolve relationship conflicts through individual change, and to  facilitate acceptance by each partner when individual change is not possible. The model interweaves change and acceptance throughout treatment. Interventions for change include behavior exchange; receptive and expressive communication skills training; problem solving training; mindfulness, distress tolerance and emotion regulation training (Linehan, 1993); and videotaping communication. Acceptance strategies include empathetic joining, turning the problem into an “it,” tolerance building, and self care (Jacobson & Christensen, 1998). At the end of counseling–and no matter what the source of trauma—Compton  and Follette (1998)address sexual issues, intertwined with intimacy and emotional expression.

Using various principles drawn from functional contextualism, radical behaviorism, and experiential avoidance theories, Leonard et al. (2006) modified their approach to counseling couples with a trauma history. This approach relies on treatment principles (rather than a manualized approach) as Leonard et al. (2006) believe a manualized approach is too prescriptive for couples with a trauma history. The first principle is effectiveness, and these techniques include mindfulness practice and chain analyses of problem situations. The second principle is consistency in the therapy environment, and the primary technique used is validation. The third principle is contingent responding which focuses on the use of praise as positive reinforcement, shaping, and negative reinforcement or punishment. The technique used with contingent responding is behavior exchange, which is a process where a each partner identifies behaviors he/she would like his/her partner to increase. Each partner then increases those behaviors and acknowledges his/her partner for increasing the identified behaviors. The fourth principle is modeling and uses in-session role playing with the counselor acting as one of partners to demonstrate a skill. The fifth principle is tacting (i.e., interpersonal effectiveness skills), and manding (emotion regulation skills) which pulls on dialectic behavioral therapy techniques. The sixth principle is exposure to feared feelings, topics, objects and/or thoughts. Emotional exposure is not as structured as other exposure techniques and involves encouraging and facilitating experiencing and tolerating emotions in the session. The final principle is acceptance of internal events, one’s history, and oneself and others, and involves identifying problematic controlling strategies for internal experiences by using metaphors and exercises from acceptance and commitment therapy.

Resources:
Integrative Behavioral Couple Therapy. http://ibct.psych.ucla.edu/about.html

Emotionally-Focused Couples Therapy (EFCT)
Recent studies (Dalton, Greenman, Classen, & Johnson, 2013; MacIntosh & Johnson, 2008) indicate that EFCT is effective for couples in which the female partner in a couple is an intrafamilial childhood abuse survivor. EFCT is a three stage model based on attachment theory (Johnson, 2002). Stage 1, stabilization, involves: (a) creating a safe place and trusting therapeutic relationship, and (b) clarifying interactional patterns and the emotional responses that shape these patterns. Interventions for the first goal include empathetic reflection, validation, empathetic inference, and collaborative problem solving about safety issues. Interventions for the second goal include tracking and summarizing interactions and reflecting and expanding underlying emotions. The second stage, restructuring bonds through building self and relational capacities, includes (a) expanding and restructuring emotional experiences, (b) expanding self with others, and (c) restructuring interactions toward accessibility and responsiveness. The third stage, integration, occurs on three levels: self-definition, relationship definition, and each partner’s resilience to traumatic stress. Interventions include constructing an empowering story of change process, fostering pragmatic problem solving of divisive issues, and heightening bonding responses and events that define the relationship as a secure attachment.

Resources:
The International Centre for Excellence in Emotionally Focused Therapy. http://www.iceeft.com/

 

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