Conceptualization Of Comorbidity Of Family Problems

For depressed individuals who are experiencing family difficulties, the cognitive therapist may develop an integrative case conceptualization that takes into account family and interpersonal issues, as well as individual cognitions, emotions, and behaviors. A few points about conceptualizations bear mentioning here. As Jacobson and Christensen (1996b) point out, a conceptualization (or formulation) is not a static concept; rather, it evolves and changes over time as new information is introduced. In addition, a conceptualization does not represent the absolute truth; rather, it is a social construction that derives its value from how useful it is for the patient and family members.

An integrative (interpersonal and intrapersonal) conceptualization takes into account the emotions, cognitions, and behaviors of the depressed patient, as well as those of his/her family members. Both self-schemas and interpersonal schemas should be assessed; that is, one must consider how family members view themselves and the world, as well as their relationships with others. Most importantly, what makes the conceptualization truly inte-grative is an understanding of the transactional patterns that occur between different individuals in the family; that is, how a given individual's thoughts, feelings, and behaviors impact on the thoughts, feelings, and behaviors of other family members, and how other family members have an impact on that individual. How do these cycles serve to maintain or limit depression in the family? Finally, the therapist also needs to consider the impact of external stressful situations on family members.

We believe that, in most cases, conceptualizations are most useful when no one is blamed for depression or for problematic family interactions. Rather, the conceptualization focuses on differences between people (e.g., different expectations), a mismatch between a person and a situation, trans-actional patterns that may have been functional at one point but are no longer useful, or a stressor that activates an underlying diathesis. Therapy, then focuses not on blame, but on responsibility for or commitment to change.

In some cases, family problems may precipitate depression; in others, the depression may occur first. Many times, family problems and depression have a complex reciprocal impact on each other: as family problems increase, depression worsens, which may in turn lead to more problems within the family. Family problems that may contribute to the cause of depression include (but are not limited to) history of childhood abuse, aggression within the current family, infidelity, conflict, alcohol or drug problems, and care-giving for an ill relative. Changes in family structure, such as a birth or a child leaving for college, are stressors that may also contribute to or maintain depression. Problems that may be a consequence of depression include symptoms of depression that have an impact on other family members, such as sexual problems, criticism, negativity, anger, decreased interest in other family members or inability to fulfill family responsibilities, or poor problem solving. Suicidal thoughts or attempts may precipitate a family crisis, with other family members feeling a host of negative emotions, including anxiety, anger, shock, grief, or guilt. Because it is hard to know how best to cope with depression in a loved one, the way family members react to a depression may also lead to difficulties. For example, family members may become overprotective if a family member is depressed, and shield him/her from activities that may actually be helpful (e.g., social activities). Family members may not have a good understanding of depression, and may blame the depressed individual for depression symptoms. Alternatively, family members may blame themselves or each other if another family member is depressed (e.g., parents may blame each other for a child's problems).

To illustrate, we give a brief example of a cognitive case conceptualization, then an example of the same case with an integrative cognitive-interpersonal case conceptualization.

Jane presented to a cognitive therapist saying that she had been feeling depressed and tearful since her marriage 6 months earlier. Her problem list included frequent fights with her husband Bill, not having very many female friends, and being dissatisfied with her work as a teacher. Frequent cognitions included "My husband doesn't care about me," "I'll never make more friends," and "Nothing ever goes right for me." Jane had a deep-seated fear of being alone in the world. She reported that she did attempt to discuss her feelings with her husband, but that he was not interested in hearing about how she felt. She described Bill as uncaring, distant, and cold.

After meeting with both Jane and her husband, the cognitive therapist expanded the case conceptualization further by integrating how Jane's and Bill's thoughts and behaviors interacted. She found that each had come into the marriage with different expectations. Jane expected to experience a new level of closeness, above and beyond what she had felt when they were dating. Bill expected things to continue exactly as before, and he continued to spend two nights per week out with friends. Jane was disappointed and started to feel unloved, interpreting her husband's behavior (i.e., being with friends) to mean that he did not care about her. As she became more convinced of this interpretation, Jane requested that he spend more time with her. Bill said that he cared a lot for Jane, so he tried to comply, but he did not want to give up his nights with his friends. Jane began to think that the only way she would know Bill cared about her was if he gave up those nights, and she told him so. This felt very threatening to Bill, and he became determined that he could never give up his nights out. Bill clearly expressed the desire to "make his marriage work" even though he was frustrated because he did not know how to improve things. The partners were polarized in a classic "demand-withdraw" pattern (Christensen & Heavey, 1990): The more Jane demanded, the more Bill withdrew from her; conversely, the more he withdrew, the more depressed and anxious she felt, and the more she demanded from him.

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