Couple & Family Therapy : An Integrative Map of the Territory Jay L Lebow Chapter 3 The Empirical Base

Introduction Science & a Craft Origins in Theory Growth in Science (Lebow, 2014) Introduction Science & a Craft Origins in Theory Growth in Science

Relevance of Science Two levels Local – local clinical scientist (Lebow, 2014) Relevance of Science Two levels Local – local clinical scientist Science based perusal of data to make clinical decisions Testing hypotheses Gathering data of feedback General Gathering knowledge across all families/practices

Clinical Decision Making (Lebow, 2014) Clinical Decision Making Best data from clinical trails Too complex to put into algorithms Too many decisions to make Too many possible options Limits to applicability to any one family

What does research offer? (Lebow, 2014) What does research offer? Relatively little research done in the past that could inform practice Some supported treatments exist Research provides objective documentation Efficacy/ evidence based practice Reimbursement Research provides info on best practices

What does research provide? (Lebow, 2014) What does research provide? Probabilities Similar cases Options that have worked/ not worked Objective Assessments Expand beyond biases Efficacy of specific decisions Correlations Ex: schizophrenia and expressed emotion

Limits of Research Poor research designs Fads (Lebow, 2014) Limits of Research Poor research designs Fads Not enough control over variables

What can clinicians offer research? (Lebow, 2014) What can clinicians offer research? Generating ideas for research Providing feedback Application in the real world

Quality of Research in Family Therapy (Lebow, 2014) Quality of Research in Family Therapy Time - Longitudinal studies are increasing in number Growing external validity - Increasingly multicultural Children of Divorce Children of Same-sex Parents

Demographics of Marriage & Family (Lebow, 2014) Demographics of Marriage & Family Goal of therapy is strengthening relationships. Families have a variety of options other than “institutionalized marriage” Single or Two-Parent? Only a slight majority of children live with two parents Single parent families are the norm

Demographics of Marriage & Family (cont) (Lebow, 2014) Demographics of Marriage & Family (cont) Divorce = 50% Half of divorces take place in the first 7 years of marriage Cohabitation = 8% Rates of break-ups are higher than divorce Predominant living arrangement is living alone

Epidemiology of Couple Distress (Lebow, 2014) Epidemiology of Couple Distress 20% (1/5) of couples are “distressed” at any point in time Satisfaction levels decrease significantly over the first 10 years Relationships are the most frequently cited source of emotional distress

Couple Distress Impacts individual psychopathology (Lebow, 2014) Couple Distress Impacts individual psychopathology Couple distress is linked to Axis 1 disorders Anxiety, mood, & substance related Expressed emotion Schizophrenia, bipolar, borderline personality, Etc. Social functioning (Whisman & Uebelacker, 2006) Social role functioning General distress Poorer physical health Increase of suicidal ideation Poorer outcomes in individual therapy

Effects of Relationships (Lebow, 2014) Effects of Relationships “Patterns in family process and child rearing have vital and lasting effect on the development of virtually every personality characteristic and form of psychopathology” (p. 68)

Caveats for Effects of Relationships (Lebow, 2014) Caveats for Effects of Relationships Correlation NOT Causation Circular Depressed people more likely to enter more difficult relationships which is more likely to lead to depression System issues do not exist in isolation Individual differences impact families

Characteristics of Relationships (Lebow, 2014) Characteristics of Relationships What is satisfying and what is distressing? Positive Sentiment Override (PSO) is satisfying Positive feelings & behaviors outweigh negative ones Gottman says 20:1 Negative sentiment override is distressing Feelings have greater impact than behavior changes How would you assess for PSO? How can you increase PSO?

Characteristics of Relationships (Lebow, 2014) Characteristics of Relationships Separation of Positive & Negative Aspects of Relationships Problems & Successes are independent Don’t loose focus of what is working in a relationship

Conflict in Satisfying Relationships (Lebow, 2014) Conflict in Satisfying Relationships Governed and focused May have high emotion Positive or neutral affect is mostly present

Conflict in Distressed Relationships (Lebow, 2014) Conflict in Distressed Relationships Unfair fighting Name-calling Not listening Multiple Issues in One Fight Flooding of Negative Affect Prusuar-Distancer Cycles

(Lebow, 2014) Gottman’s Research Intensive coding of videotaped interactions, assessments, interviews, Etc. Goal of therapy: Increase positive exchange Decrease negative exchange The Four Horsemen Criticism Defensiveness Contempt Stonewalling

Gottman’s Research (cont.) (Lebow, 2014) Gottman’s Research (cont.) Topics of conflict same Repeating the same fights happens to all couples Amount of conflict doesn’t really matter PSO needs to stay high Accurate communication of feeling May help develop intimacy, but… Is not helpful for highly contemptuous feelings

Attachment Assessment (Lebow, 2014) Attachment Bowlby - “Safe Base” Early life experiences lead to attachments that are… Secure Insecure Avoidant Assessment How do families sooth one another, connect, and maintain closeness? Low attachment predicts dissatisfaction only when one or more members need attachment https://www.youtube.com/watch?v=apzXGEbZht0

Communication Most frequent focus of couple and family therapy (Lebow, 2014) Communication Most frequent focus of couple and family therapy Typical interventions Modeling Practicing speaking & listening

Speaker Listener Technique (Lebow, 2014) Speaker Listener Technique RULES FOR BOTH: 1. The speaker has the floor. 2. Share the floor. 3. No problem solving. RULES FOR THE SPEAKER: 1. Speak for yourself. 2. Talk in small chunks. 3. Stop and let the Listener paraphrase. RULES FOR THE LISTENER: 1. Paraphrase what you hear. 2. Don’t rebut. Focus on the Speaker’s message.

Gender Differences Gender affects (Lebow, 2014) Gender Differences Gender affects Distribution of work Responsibilities Expectations Co-equal relationships have greater satisfaction Reality - Even in two fulltime working parent households, women have a greater amount of work in the home Discuss when contributing to the issues

Family Violence Highly underreported, even among couples in therapy (Lebow, 2014) Family Violence Highly underreported, even among couples in therapy Correlated with High conflict Angry outbursts Difficulties with self control Low grade interactions especially high Pushing, slapping Under-reported Gender Defined as slapping, pushing, Etc. – equal

Family Violence (cont.) (Lebow, 2014) Family Violence (cont.) Batterers - mostly men 20% poor prognosis for change Antisocial behavior Lack of remorse Lower levels of psychological arousal when stressed Family therapy is an invitation of risk, and most likely not effective

(Lebow, 2014) Divorce & Remarriage Divorce/ separation & remarriage/ newly cohabitating causes turbulent years Two years of adjustment for divorce/separation Remarriage Normal to be less cohesive than original families Better to gradually/slowly integrate

(Lebow, 2014) Family Rituals Stabilizing Effect Dinner hour What else?

(Lebow, 2014) Reference Lebow, J. L. (2014). Couple and family therapy: An integrative map of the territory. Washington, DC: APA books.