Varda Shoham

Empirically Supported Couple and Family Interventions for Marital Distress and Adult Mental Health Problems

This article evaluates the efficacy, effectiveness, and clinical significance of empirically supported couple and family interventions for treating marital distress and individual adult disorders, including anxiety disorders, depression, sexual dysfunctions, alcoholism and problem drinking, and schizophrenia. In addition to consideration of different theoretical approaches to treating these disorders, different ways of including a partner or family in treatment are highlighted: (a) partner-family-assisted interventions, (b) disorder-specific partner-family interventions, and (c) more general couple-family therapy. Findings across diagnostic groups and issues involved in applying efficacy criteria to these populations are discussed.

Prognostic Importance of Marital Quality for Survival of Congestive Heart Failure

Mounting evidence indicates that social support is associated with better outcomes of cardiovascular disease and reduced all-cause mortality. Much less is known about the specific contribution of marital functioning to these outcomes, and the potential prognostic significance of marital quality for congestive heart failure (CHF) has not been explored. Interview and observational measures of marital quality obtained from 189 patients with CHF (139 men and 50 women) and their spouses were examined as predictors of patient survival up to 48 months after assessment and compared with prediction based on illness severity (New York Heart Association [NYHA] class). Four-year survival rates were 52.5% and 68% for male patients and female patients, respectively. In Cox regression analyses, a composite measure of marital quality predicted 4-year survival as well as the patients concurrent NYHA class did (both p <0.001). Adjusting for CHF severity did not diminish the prognostic significance of marital functioning, and prediction of survival from marital quality appeared stronger for female than for male patients. Thus, when marital quality and NYHA class are considered jointly, they both make independent, statistically significant contributions to the prediction of patient mortality.

Couples coping with congestive heart failure: Role and gender differences in psychological distress

Psychological distress and marital quality were assessed with male (n = 128) and female (n = 49) congestive-heart-failure (CHF) patients and their spouses. Hopkins Symptom Check List--25 scores were in the distressed range for 57% of patients and 40% of spouses. This role difference was greater for men than for women, and a gender difference (more distress in women than men) was greater for spouses than for patients. The patients distress, but not the spouses, reflected the severity of the patients illness, and distress for both partners correlated negatively with ratings of marital quality. Female-patient couples reported better relationship quality than male-patient couples, however, and a mediation analysis indicated that the gender difference in spouse distress could be explained by marital quality. Results highlight the contextual nature of CHF distress and suggest that role differences in distress vary by gender.

Demand–withdraw couple interaction moderates retention in cognitive–behavioral versus family-systems treatments for alcoholism.

Individually focused Attribute × Treatment interaction (ATI) research has neglected attributes of couple and family relationships that may moderate response to different treatments. Sixty-three couples with a male alcoholic partner participated in up to 20 sessions of either cognitive-behavioral therapy (CBT) or family-systems therapy (FST). As hypothesized, couples high on pretreatment measures of demand-withdraw interaction (DWI) attended fewer sessions of CBT, whereas DWI made little difference in FST. A specific, alcohol-related wife-demand/husband-withdraw pattern moderated retention more than the opposite husband-demand/wife-withdraw pattern, although the general affective quality of a couples relationship may have contributed to ATIs as well. Results illustrate the importance of relational moderators in ATI research and suggest possible benefits of matching alcoholics to treatments when the unit of treatment involves more than 1 person.

Rebooting for Whom? Portfolios, Technology, and Personalized Intervention.

We share Kazdin and Blase’s (2011) sense of urgency about finding better ways to reduce the burden of mental illness. Although effective psychosocial treatments exist, they do not often reach the patients who need them most. Kazdin and Blase’s portfolio approach aims to cast a wider net through increased use of technology, media, self-help, nonprofessional providers, and collaborations with other disciplines. It is unclear, however, whether reaching more people would suffice to reduce the burden of mental illness, much less offset the small effect sizes of simplified, scaled-down interventions such a portfolio approach would likely entail. We focus here on an underdeveloped theme in Kazdin and Blase’s essay—that bending the curve of mental illness will require better knowledge of for whom simplified intervention and prevention strategies will suffice and for whom more intensive intervention is necessary. Such “for whom” questions deserve a central place on the national research agenda as we move toward individualized or personalized health care. In the absence of such knowledge, we risk treatment decisions guided by accessibility to resources rather than patient needs—the very problem Kazdin and Blase aim to solve.

Symptom-system fit in couples: emotion regulation when one or both partners smoke.

In a laboratory smoking experiment, 25 couples in which 1 or both partners continued to smoke despite 1 of them having heart or lung disease discussed a health-related disagreement before and during a period of smoking. Immediately afterward, the partners used independent joysticks to recall their continuous emotional experience during the interaction while watching themselves on video. Participants in dual-smoker couples reported increased positive emotion contingent upon lighting up, whereas those in single-smoker couples reported the opposite. The results highlight the role of smoking in close relationships, particularly in regulating emotional closeness when both partners smoke. Attention to this fit between symptom and system may be useful in helping couples achieve stable cessation.

Interrupting Ironic Processes

Research on ironic mental control processes makes the underappreciated point that attempts to solve problems sometimes make them worse Social scientists now know much about what ironic processes look like less about why they occur and too little about how to change them. Features of the exacerbation process itself suggest parsimonious approaches to treatment based on interrupting the “solutions” that keep ironic mental processes going (eg compliance-based paradoxical intervention) Extending Wegners explication of ironic intrapersonal (mental) processes we propose that ironic interpersonal (social) processes also maintain many human problems and may be more accessible to intervention Treatment development in this area will benefit from attending more to how problems persist than to how they originate, and from targeting ironic cycles that occur between people as well as within them

Gender Differences in Quit Support by Partners of Health-Compromised Smokers

In a study of spousal support for smoking cessation, 34 couples in which one partner continued to smoke despite having a heart or lung problem used an adaptation of Cohen & Lichtensteins (1990) Partner Interaction Questionnaire to describe the spouses attempts to help the primary (ill) smoker quit. Female smokers received less support for quitting from their spouse or partner than male smokers did, regardless of whether the support was positive or negative, whether the partner also smoked, or whether the smoker or partner rated the partners support behavior. Female patients in a treatment sub-sample were also less likely than men to achieve stable 1-year cessation if the couple had rated partner support at baseline as coercive or unhelpful. Given known gender differences in relapse risk, cessation interventions for health-compromised female smokers might profitably include partners in addition to the smokers themselves.

A cross‐sectional assessment of the long term effects of brief strategic family therapy for adolescent substance use

BACKGROUND Young adult drug use and law-breaking behaviors often have roots in adolescence. These behaviors are predicted by early drug use, parental substance use disorders, and disrupted and conflict-ridden family environments. AIM To examine long-term outcomes of Brief Strategic Family Therapy (BSFT) compared to treatment as usual (TAU) in the rates of drug use, number of arrests and externalizing behaviors in young adults who were randomized into treatment conditions as adolescents. DESIGN 261 of 480 adolescents who had been randomized to BSFT or TAU in the BSFT effectiveness study were assessed at a single time, 3-7 years post randomization. METHODS Assessments of drug use, externalizing behaviors, arrests and incarcerations were conducted using Timeline Follow Back, Adult Self Report, and self-report, respectively. Drug use, arrests and incarcerations were examined using negative binomial models and externalizing behaviors were examined using linear regression. RESULTS When compared with TAU, BSFT youth reported lower incidence of lifetime (IRR = 0.68, 95%CI [0.57, 0.81]) and past year (IRR = 0.54, 95%CI [0.40, 0.71]) arrests; lower rates of lifetime (IRR = 0.63, 95%CI [0.49, 0.81]) and past year (IRR = 0.70, 95%CI [0.53, 0.92]) incarcerations; and lower scores on externalizing behaviors at follow-up (B = -0.42, SE = .15, p = .005). There were no differences in drug use. CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE BSFT may have long term effects in reducing the number of arrests, incarcerations and externalizing problems. These effects could be explained by the improvements in family functioning that occurred during the effectiveness study. This study contributes to the literature by reporting on the long term outcomes of family therapy for adolescent drug abuse.

Family consultation for psychiatrically complicated health problems.

We describe a social cybernetic view of health behavior problems and a team-based family consultation (FAMCON) format for strategic intervention based on that view. This approach takes relationships rather than individuals as the primary unit of analysis and attaches more importance to problem maintenance than to etiology. Treatment aims to interrupt two types of interpersonal problem maintenance-ironic processes and symptom-system fit (conceptualized, respectively, as positive and negative feedback cycles)-and to mobilize communal coping as a relational resource for change. A case example features a depressed husband and bipolar wife complaining of severe communication difficulties related to the husbands kidney cancer and diabetes. Over 6 consultation sessions, strategic interventions focused on interrupting ironic interpersonal patterns resolved the presenting complaint. Although cost-effectiveness is an open question, FAMCON may offer a useful alternative to psychoeducational and cognitive-behavioral treatments in the framework of stepped care.