Division of Clinical Psychology
Conference 2012
Working with Older Couples In IAPT
By Dr Jonathan Hutchins
Clinical Psychologist
Referral & Assessment
• Initial referral to IAPT for 64 year old man with
depression from his GP.
• Assessed by a Cognitive Behavioural Therapist in the
team. Deemed suitable for Cognitive Behavioural
Therapy and queried current level of cognitive ability.
• CBT therapist referred him to the memory clinic for
assessment and they came back stating that he had
mild cognitive impairment. Therefore, CBT was still
appropriate in the CBT therapists view.
Initial Cognitive Behavioural Therapy Session
• Met John for first time and he stated that he felt low
in himself and highlighted a level of self loathing – “I
am just a worthless waste of space” and “I should be
able to do more than what I am but I just can’t be
bothered”.
• John highlighted that he lost his job in the services
10 years ago which he blamed himself for and that
he had been “lost” ever since. He stated that he had
tried charity work but that this did not work out.
Initial Cognitive Behavioural Therapy Formulation adapted from
Laidlaw et al (2004)
Early Experiences
Cohort Beliefs
Family did not do emotions –
suppressive coping – just got on
with it.
You just get on
with things.
Father in the forces
You can’t teach
an old dog new
tricks.
Core Beliefs
I am useless
I am worthless
Role Investment:
Was the bread
winner and was
very successful in
his job.
Rules for living
I should be doing something otherwise
I am a useless waste of space
Perfectionist
Activating event:
Loss of job through
his boss forcing
him to either
accept demotion or
to leave.
Socio-cultural
Context: White
British middle
class man grew up
in time of
traditional values
Problems: Low mood, withdrawal from activities, lots of self attacking NATS.
Cognitive Behavioural Intervention and Why We
Moved to Couples Work
• Saw John for 5 sessions of CBT focused on addressing
his low mood.
• CBT had some positive effect in reducing self
criticism, increasing positive activities (such as going
to the gym with his wife) and reduced his depression
and anxiety scores on the PHQ-9 and GAD-7 from
moderate to mild.
• Then John talked a lot about his concerns in his
relationship with his wife and how was having
arguments and feared losing her.
Beginning of Couples Therapy Work
• Saw John and Susan to begin couples work based on
Integrative Behavioural Couples Therapy.
• Identified two key difficulties in the relationship – the
first being the role of seeing visitors, where Susan
was very sociable and John would become worried
and anxious if he were to see people.
• The second issue was related to Johns experience of
low mood and self loathing which Susan found very
difficult to take.
Couples Therapy Formulation
• Predisposing factors:
– Relationship had been in traditional roles with Susan
being more of a house wife and John being the primary
bread winner.
– John met Susan in Ireland and Susan was used to him
having a very successful career.
• Precipitating factors:
– John’s loss of job role and then him becoming more
dependent on Susan for social interaction and meaning
in his life.
– Susan found this a strain on her as she was used to
living more independently seeing friends.
Couples Therapy Formulation (2)
• Maintaining Factors: Adapted from the systemic
concept of circularity (Cecchin, 1987):
John: I know I am a useless waste of space and
if I did not have you I don’t know what I would do
Susan: You don’t need
me and your not a waste of space
John: But I do need you and
I am sorry that I upset you
Couples Therapy Intervention
• Had five sessions of Integrative Behavioural Couples
Therapy (Christensen, Jacobson & Babcock 1995).
• Focused initially on externalising the depression or
self loathing where Susan and John called it “the
chair” (White, 2007).
• Addressed Susan’s and Johns different needs around
social engagement by both parties moving towards a
compromise in that Susan would tell John ahead of
time if visitors were coming and she would plan for
visitors when John was in the gym.
Couples Therapy Intervention (2)
• On our third session Susan stated that John had been
assessed by the memory clinic recently and that they had
diagnosed him with Alzheimer's type Dementia.
• Susan reported feeling very shocked at the diagnosis but she
felt John had responded well to it. John stated that he viewed
the diagnosis as an “excuse” but he was glad that it was
pinpointed.
• We then focused the remainder of our work on forming a
“bucket list” coming up with ideas of things that they could do
before the dementia progressed further.
• Both Susan and John responded very well to this and stated
that “the chair” had been less when they were on holiday in
Ireland. Therefore, we focused the session on making plans on
what future holidays they could do.
Couples Therapy Evaluation
• I saw Susan and John for two more sessions following
the dementia diagnosis.
• They stated that they had made plans to visit South
America and that they planned to make the best of
things before the dementia progressed.
• They stated that “the chair” was much less dominant
in their lives.
• John stated that in response to the dementia
diagnosis: "I have accepted the issues that I have and
I plan to make the best of the time I have got.”
References
• Cecchin, G. (1987). Hypothesizing, circularity and neutrality revisited: an
invitation to curiosity. Family Process, 26(4), 405-13.
• Christensen, A., Jacobson, N.S. & Babcock, J.C. (1995). Integrative
behavioral couples therapy. In N.S. Jacobson & A.S. Gurman (Eds.) Clinical
Handbook for Couples Therapy (pp. 31-64). New York: Guildford.
• Laidlaw, K., Thompson, L. W. & Gallagher-Thompson, D. (2004).
Comprehensive conceptualization for cognitive–behavioural therapy for
late life depression. Behavioural and Cognitive Psychotherapy 32, 389–
399.
• White, M. (2007). Maps of Narrative Practice. New York: W.W. Norton.