Published September 2016Victoria 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).
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.shtmlIDENTIFICATION/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,
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
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Published June 2015
Catherine J. Brack and Greg Brack, Georgia 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.
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.
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).
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/
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.
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.
The International Centre for Excellence in Emotionally Focused Therapy. http://www.iceeft.com/
Alexander, P. (2008). Dual-trauma couples: Why do we need to study them? Retrieved from http://www.wcwonline.org/Research-Action-Report-Fall/Winter-2008/dual-trauma-couples-why- do-we-need-to-study-them
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