Helping Couples Improve Their Relationships

MARRCH Annual Workshop1-2:40 & 3-4:40 pm 10/30/07Doug Greenlee MA/MS LMFT, LADC, CGC

Staff Psychotherapist, Recovery Plus Addiction & Mental Health Center

Greenleed@centracare.com

Goals & Objectives

To highlight biopsychosocial evidence-informed relational enhancement models that may be useful for reducing conflict and enhancing intimacy skills in couple and/or family relationships

To provide opportunity for attendees to review and to discuss sample case scenarios via practice identifying basic issues, implementing problem solving and enhancing intimacy skills development

Logistics

Learning level: Beginner Core Functions: Counseling & implications Presenter Information: Experience &

Education Presentation summary: Evidence-informed

relational enhancement models Client? Cultural Diversity: Client as Cultural Unit Ethics: Informed consent, confidentiality

limits, dual licensure & gray areas

Overview

Biopsychosocialmodel

Brain & Addiction Basics

Clinician’s Role& Clinical Process

Therapeutic Strategies

Applied Exercise

Biopsychosocial Overview(Campbell, W. & Rohrbaugh, R., 2006)

Biological/Descriptive Data Base

Symptoms: Mood, Anxiety, Cognitive, Substance, Psychotic, Personality, Somatic

Predispositions: Genetics, Physical Conditions, Medications/Substances

Demographics: = disorder & epidemiology

BPS cont.

Psychological Formulation

Vulnerabilities: developmental disruptions, revelatory statements/behavior, recurrent relationship difficulties

Psychosocial Stressors: Why Now?

BPS cont.

Psychic Consequences: Strong emotions, thoughts/fantasies, subtle changes in cognition

Coping mechanisms: Adaptive, maladaptive

Psychodynamic Formulation: Dependency, Control, Self-esteem, Intimacy/triadic relationships

BPS cont.

Cognitive Perspective: Dysfunctional automatic thoughts, Negative core beliefs, cognitive distortions

Behavioral Perspective: Reinforcement for maladaptive behavior? Something extinguishing a desired behavior? Paired association between behavior/environmental cue initiating behavior?

BPS cont.

Social Formulation/Database Social Stressors & Strengths: Family,

SO/friendships, social issues, education, work, housing, income, health care access, legal/crime

Cultural/Spiritual: C/S-- identity, explanations of illness, psychosocial environment/functioning level, therapeutic alliance dynamics

BPS cont.

Prognosis Compliance with treatment

Response to prior treatment

Availability of treatment

Personality/defense mechanisms

Social supports

Addiction Science Overview(Erickson, C., 2007)

Brain Disease Nervous system functions: Sensing, integrative, &

motor Nervous system: CNS, PNS Neurochemicals: Dopamine, Serotonin,

Norepinephrine, Acetycholine, Endorphins, Endocannibinoids, Glutamate & Gaba

Reward pathway: Mesolimbic Dopamine System Disease: Genetic vulnerability, neuroadaptation

synaptic plasticity & sensitization/desensitization, dysregulations

Addiction Science cont.

Neurobiological Theories of Dependence

Allostasis

Pathology of motivation and choice

Incentive socialization

Learning and memory mechanisms

Affective Neuroscience(Atkinson, B. 2005)

The Emotional Brain Neural architecture favors emotional influence Rational decision making emotion dependent Brain/emotion mechanisms Emotional memory Neural back alley Unconscious emotional influence Neural hijacking

Affective Neuroscience cont.

Integrating Neural Knowledge Cultivate greater awareness of emotional influences Treat emotional states as if they had minds of their

own Attend to emotional states before pursuing other

therapeutic goals Focus on the stance clients take toward their

emotional states Work with emotional states when they are active Seek cooperation from not control over emotional

states

Affective Neuroscience cont.

Special Purpose Mood States

Executive operating systems: “State of mind is a pattern of activation of recruited systems within the brain responsible for: 10 perceptual bias, 2) emotional tone & regulation, 3) memory processes, 4) mental models, 5) behavioral response patterns.”

State activation: motivation to accomplish critical survival tasks

Affective Neuroscience cont.

Brain’s Executive Operating Systems

Rage: Evolutionary advantage/self-protection Fear: E/A - escape danger Seeking: E/A – learning/agency in the world Lust: E/A – motivation to reproduction Care: E/A – protection of loved one’s Panic: E/A – motivation for affiliation/support Play: E/A – social bonding, creativity, healing

Co-Occuring Disorders

Marital Distress & Psychiatric Disorders Epidemiological Study (2000)

Major depression Social Phobia Simple Phobia Panic Disorder Generalized Anxiety Disorder Alcohol dependence/Abuse

Attachment Dynamics

Secure

Low Anxiety

Dismissing Avoidant

High Avoidance

Fearful Avoidant

High Anxiety

Preoccupied

Low avoidance

Adult Attachment

Styles

Cultural Competence Process & Health Care

Cultural Competence Healthcare Models

Campinha-Bacote Model: Desire, Awareness, Knowledge, Skill & Encounter (see handout)

Purnell’s model for cultural competence: Unconsciously incompetent; Consciously incompetent; Consciously competent; Unconsciously competent. (see handout)

Sequential & Pluralistic Couple’s Therapy Process Model

Examine developmental sources of

relationship distress Challenge cognitive components of

relationship distress Promote relevant relationship skills Strengthen the couple dyad Contain disabling crises Establish a collaborative alliance

Therapeutic Alliance

Transtheoretical Dimensions Engagement in the therapeutic process

Emotional connection with the therapist

Safety within the therapeutic system

Shared sense of purpose within the family

Therapeutic Alliance cont.

SOFTA-O: System for Observing Family Therapy Alliances—Observational

Engagement: Client/Therapist version

Emotional Connection: Client/Therapist version

Safety: Client/Therapist version

Shared Purpose: Client/Therapist version

Partnership(Dr. Jan Hoistad)

Basic Styles Traditional – dominant & non-dominant

Merged – fused personal boundaries

Roommate – independent & unilateral

Big Picture Partnering – your, my & our world

Big Picture Partnering:10 Essentials

Create & maintain positive feelings Talk regularly & take turns listening Regularly renew your commitment Stay committed to Big Picture Make win/win decisions Pull your own weight Make & keep clear agreements Partnering is joint effort Problem solve relationship together Create new options

The Four Horseman of the Apocalypse

Criticism

Defensiveness

Contempt

Stonewalling

Relational Success

Managing Conflict Prerequisite: 1 Soft Start-up Prerequisite: 2 Accepting Influence Prerequisite: 3 Effective Repair Prerequisite: 4 Respecting Partner’s Dreams

Connecting During Non-Conflict Times Prerequisite: 5 Five Positives – 1 Negative

Relational Success: Predictive Habits

Soft Start-Up Avoiding a Judgmental Attitude Standing Up for Yourself Without Putting

Your Partner Down

Accepting Influence Finding the Understandable Part Giving Equal Regard

Relational Success: Predictive Habits

Effective Repair Offering Assurances

Respecting Your Partner’s Dreams & Holding on to Your Own

Understanding & Explaining What is at Stake

Relational Success: Predictive Habits

5 Positives for Every Negative

Curiosity about Your Partner’s World Keeping Sight of the Positive Pursuing Shared Meaning Making and Responding to Bids for

Connnection

Common Issues

Workaholic – Where do we fit? The Affair – Can I/we get over it? Crises – Yes! Problem solving but intimacy? Stonewalling – Why don’t we talk anymore? Dream loss – What about my/our dreams? Depressed – Why so distant & irritable? Frustrated – So, I’m a nag? Dead-in-the water – Where’s the fun? Children-focused – What about Us? Dramatic – Is it really that complicated?

Conversation Practice

Living Your Dreams Together: Conversation Cards for Couples by Dr. Jan Hoistad

The Art of Conversation & The Ouchkit: Couples Therapy in a Box by Betsy Sansby MS LMFT

Interpersonal Effectiveness Skills: DEARMAN GIVE & FAST by Dr. Marsha Linehan

The Peaceful Heart: A practical guide to unconditional love and forgiveness by Mary Hayes-Grieco

Ethics & Law

Universal Ethics Beneficence Non-malefalence Preserving Independence Fidelity or True to Purpose Justice

Legal Informed consent Confidentiality

Summary & Application

Biopsychosocial model & Addiction dynamics in early recovery

Strategic role of the clinician as guiding interpersonal problem solving

Basic paper & pencil or related activities for identifying, stimulating & potentially resolving interpersonal issues

Review of handouts & bibliography Applied exercise(s)