Abstract
In western cultures, by the age of 50 about 85 per cent of people have been married at least once; about one-third to half of couples separate or divorce; about half of all divorces occur in the first 7 years of marriage; of couples that remain married about 20 per cent experience relationship distress and, compared with distressed or separated couples, those who sustain mutually satisfying relationships have better physical and mental health, live longer, experience better financial prosperity and engage in better parenting practices, and their children have better academic achievement and psychological adjustment.
In a recent review of the evidence base for family therapy and systemic practice, Carr (2014) writes about relationship distress. In this editorial, I would particularly like to draw the reader’s attention to the latter part of this quote and briefly consider its implications. It is my intention to raise the profile of couple work in a work context which has historically not been inclusive of couple therapy or couple work into their service provision. From my experience as the Lead of the Family Therapy Department in a Child and Adolescent Mental Health Service (CAMHS) in the United Kingdom, it has become clear to me that we ought to include working with the couple relationship more often, if not as standard in our practice.
In order to effectively work with children, one needs to take account of their environment. The first and immediate environment is the home environment. This home environment may consist of the biological parents, a step-parent or an adoptive parenting couple or even foster carers. The final two family constellations may have some specific issues attached to them, but essentially in order to help and reach out to a child, one needs to include such areas into one’s formulation and practice (e.g. Tarren-Sweeney & Vetere, 2013). I think that most therapeutic approaches have the view that the context around the child is vitally important to engage with directly or indirectly. There may be differences between how immediate this engagement is, with Family Therapies arguably working with more family members directly in the therapy session, whereas other approaches, such as cognitive behavioural therapy (CBT) or Psychodynamic Psychotherapies, working more indirectly with the home environments through reviews and perhaps keeping that context in mind while working individually with a child or an adolescent.
When working with parents of children who present with emotional or behavioural difficulties, the perspective is often in terms of attachment processes and social modelling. The work is often dyadic with the parent and child relationship central to this piece of work. Parents are consulted about their own part in that relationship. This could be due to their own histories or present stresses and strains. This is a valuable perspective when it comes to identifying the factors that have been impacting on the development of a child. When the work is more focussed on the parents’ relationship, it is mostly about how the parents can work more effectively as a team together. Issues of communication and supporting each other regarding specific parenting tasks are the main focus of this work. Parenting programmes have been developed from communication models, which are being offered across the world with a variety of research evidence supporting their effectiveness (e.g. Mejia, Calam, & Sanders, 2012; Moran, Ghate, & Van Der Merwe, 2004; Sanders, Markie-Dadds, & Turner, 2003). These programmes seem to view the parenting couple as two individuals on a team doing a task. When working with parenting couples, the adult relationships with the child or children are prioritised. The role that is being privileged is that of parent, not of partner.
Social care agencies in the United Kingdom already use an essentially systemic framework which takes into account the various contexts around the child (Department of Health, Department for Education and Employment, & Home Office, 2000). ‘Child’s development’, ‘parenting capacity’ and ‘family & environmental factors’ are all dimensions which are recognised as important when we look at a child’s life and his or her needs. The model used in Child Practice informs both assessment and practice. Similarly, a comprehensive mental health assessment would look at various contextual factors, from the individual to the relational and environmental. These may include enquiry into the factors that may have affected a child’s development in utero.
I believe that despite these contextual perspectives in the areas of child welfare and mental health, the importance of healthy couple life to creating and maintaining a healthy family life is often not in focus. Child and Adolescent mental health practitioners are advised that if it has been identified that a couple have issues related to their couple relationship, to refer the parents to an agency or marriage/couple therapist to work exclusively with the couple. This arrangement makes sense from a perspective that the child has their own individual needs and if his or her development is impacted on, then this would need to be approached or dealt with through the relationship with the parent directly. The result is that the assessing or treating psychotherapist or psychologist may do some dyadic work consisting of the child and one of the parents or carers. Parenting courses which are more workshop-based and often use a social learning or behavioural model may go beyond this when they discuss the need for parents to work together. The parenting couple may be included directly in the intervention, but again, the topic of discussion is the relationship with the child, or the fact that the parents need to be united and act as one and ‘sing from the same song sheet’, in order to be more effective in relation to the child or children about whom there are concerns.
There are some systemic frameworks that acknowledge the importance of attending to the couple relationship in family therapy (e.g. Attachment Narrative Therapy (ANT): Dallos, 2006; Attachment-Based Family Therapy (ABFT): Diamond, Diamond, & Levy, 2014). Attachment processes of parents are explored in the context of being a parent and then trans-generationally as a child to their own parents (ANT: Dallos & Karamat Ali, 2014) or work is done with parents to ‘resuscitate parental empathy for the adolescent and get parents committed to and prepared for the attachment task’ (ABFT: Diamond et al., 2014, p. 129). These more relational, emotionally focussed and reflective approaches when working with parents and families are a great development, but in terms of incorporating conversations and explorations about the quality and functioning of the parental couple relationship, they have not been able to accommodate such explorations in the therapy.
Challenges for adopting an additional focus on the parental couple relationship
There are arguably three main areas that need to be considered if we are to consider finding ways of working with the couple relationship. There are the challenges for the clinician or practitioner, then those for the family or the parents and a third one might be captured by organisational challenges.
The challenge for the therapist may be that he or she needs to step outside of their comfort zone. In a previous editorial piece titled ‘Taking risks (by examining our practice) – Encouragement to address the couple relationship’, I shared my view about the perceived risks that clinicians in child and family work often face (Karamat Ali, 2010). One of the main ones is the fact that couple relationships can feel rather volatile or intense. I am not advocating unsafe practice or encouraging people to go beyond their level of experience and outside of the scope their training allows. On the other hand, one should not underestimate how much clinical experience child and adolescent (mental health) workers have of working with parents. I am advocating for therapists to start to think about that parental relationship in a more multileveled way. Not to see the parents in that specific role in relation to their child(ren), but also as children themselves who have grown up and specifically as a partner to the other parent or step-parent. The quality of this relationship can come into focus (like a lens to a camera) without having to take over the entire therapeutic endeavour. In order for the practitioner to be venturing into a more systemic and inclusive practice and include a therapeutic focus on the couple as described here, high quality and robust clinical systemic supervision is essential.
The challenge for the family or parents may be to start to think about their own relationship and how it may have more of an impact or influence on the lives of their children than is usually thought. Clinical experience will tell us that if they think about their couple relationship or intimate adult relationship in relation to their children, it is often how the child’s behaviour is negatively impacting on the couple relationship. However, from a systemic perspective, we would think of a mutual influence that is taking place, which means how does the couple relationship impact on the child’s behavioural or emotional wellbeing. It is not unfamiliar for those in the child and mental health field to meet with parents who may have a narrow view of the presenting difficulties. The same skills to encourage parents, who are understandably concerned about his or her son or daughter to broaden their possible explanatory frame, can be employed here. This needs to be done sensitively and with great skill so that they remain positively curious and supportive and not feel blamed when invited to explore aspects of their couple relationship.
There may also be challenges at an organisational level when starting to address couple issues in the adult relationship within a child and mental health setting. This may be a cultural shift too far, but it may make the work more systemic and holistic to treat the whole contextual environment of the child and the factors impacting on their health. At an organisational level, changes need to be made if the couple relationship of carers is deemed part of the clinical work. At a commissioning and policy level, this would need to be recognised and a more inclusive stance would need to be taken which would support such a move away from artificial boundaries between child, family and adult mental health and emotional wellbeing. At this level, it is important that relevant information and research is highlighted which make the case that healthy parental relationships create healthy families which are vitally important for the emotional wellbeing of children. The other side of that coin is that it is already known that when the parental couple relationship is acrimonious, then it affects their emotional security (Cummings & Davies, 2010), which results in children who are more likely to develop mental health problems, or more psychological and social problems.
Final thoughts
In this editorial, I have wanted to highlight an area which is not automatically included in working with children and adolescents. Challenges of different kinds have been mentioned. I hope that this editorial piece could be a starting point to consider working more directly with couple issues in the context of child and adolescent mental health. In doing so, our assessments and treatments will become more systemic and inclusive of a dimension of a child’s life which potentially has an enormous constructive or destructive influence on his or her emotional wellbeing.