Journal of Systemic Therapies, Vol. 25, No. 3, 2006, pp.

43–57

SYSTEMIC COUPLE INTERVENTION

FOR DEPRESSION IN WOMEN
WAYNE H. DENTON
University of Texas Southwestern Medical Center at Dallas
STEPHANIE R. BURWELL
University of Georgia

Depression is a potentially life-threatening disorder that is common in the

community and in the practice of couple therapists. People experiencing
depression are more likely to experience relationship discord and vice versa.
Despite this finding, few models exist to explain the systemic understanding
of depression in the context of couple relationships for clinical practice. In
this article, the authors share their clinical experience, observations, and
conversations with women with major depressive disorder and their husbands
about their relational experience of depression. The authors suggest Emotion-
Focused Therapy (EFT) as a systemic-based model of couple therapy for
depression. Finally, a case example is presented illustrating how EFT can
be used in the treatment of depression.

Depression is the most common presenting problem seen by couple and family
therapists (Doherty & Simmons, 1996), and antidepressants are the most com-
mon psychotropic medication used by clients of couple and family therapists
(Hernandez & Doherty, 2005). In a national practice pattern study of couple and
family therapists, nearly a quarter (22.4%) of all clients were taking an antide-
pressant medication (Hernandez & Doherty, 2005). The prevalence of depression
and wide use of antidepressants make it imperative that systemic therapists under-
stand depression and how to treat it. In this paper we present information about
depression that may be useful to systemic therapists as they work with clients
coping with depression.

Address correspondence to Wayne H. Denton, M.D., Ph.D., Family Studies Center, Department of
Psychiatry, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dal-
las, TX 75390-9121. E-mail: [email protected].
44 Denton and Burwell

RELATIONSHIP DISCORD AND DEPRESSION

Research has clearly demonstrated that relationship discord and depression com-
monly coexist. A meta-analysis examining the association between relationship
discord and depressive symptoms found a correlation between depressive symp-
toms and marital satisfaction of –.42 for women and –.37 for men (Whisman,
2001). These are considered to be large effect sizes according to Cohen’s criteria
(Cohen, 1988). Whisman (2001) further found that diagnosed depression was sig-
nificantly associated with marital dissatisfaction. The relationship between
Major Depressive Disorder (MDD) and relationship discord has also been dem-
onstrated in studies of community samples (Goering, Lin, Campbell, Boyle, &
Offord, 1996; Weissman, 1987; Whisman, 1999).
To date, only one prospective study has examined the role of relationship dis-
cord in predicting diagnosed MDD (Whisman & Bruce, 1999). Relationship sat-
isfaction was assessed at baseline and then participants were reevaluated 12 months
later. Those with marital discord at baseline were 2.7 times more likely to be di-
agnosed with MDD 12 months later compared to those who reported marital sat-
isfaction at baseline. Further, marital discord accounted for almost 30% of the new
episodes of MDD (Whisman & Bruce, 1999). Together, these studies indicate that
the association between relationship discord and depression is significant and
cannot be ignored.

A SYSTEMIC VIEW OF THE ASSOCIATION

BETWEEN RELATIONSHIP DISCORD AND DEPRESSION

A hallmark of classic systems theory is that symptoms serve a communication func-

tion within the family system (Watzlawick, Bavelas, & Jackson, 1967). Lazarus
(1991) proposed a model for understanding emotions that is consistent with sys-
tems theory. In Lazarus’ model (1991), emotions are thought of as a form of inter-
nal communication that helps individuals navigate their relationship with their
environment and each emotion has a “relational theme.” Accordingly, the emo-
tion of “sadness” is associated with an appraisal that one has sustained an “irre-
vocable loss” (Lazarus, 1991, p. 122). Lazarus (1991) suggests, “One could argue
that sadness has the evolutionary function of provoking efforts at succorance from
others” (p. 252). For instance, when one witnesses someone crying in distress there
is often an instinctive urge to try to comfort the distressed person. Lazarus (1991)
suggests that depression occurs when a person begins to feel hopeless about the
implications of a loss and the psychological state of sadness becomes prolonged.
Depression in Couples 45

In support of Lazarus’ model, evidence suggests that depression is associated with

negative events (i.e., losses) in life (Kessler, 1997; Tennant, 2002).
However, Lazarus’ model does not address the relational aspects of depression.
Coyne (1976a, 1976b) proposed a systemic model of depression suggesting that
the symptoms experienced by a depressed spouse produce conflict for his or her
partner. On one hand, persistent depressive symptoms (such as irritability or loss
of interests) become aversive to the partner, but at the same time depressive symp-
toms can also elicit caring responses. Consequently, partners feel they should be
caring and helpful, but they also experience frustration and annoyance which re-
sults in feelings of guilt. While partners may try to suppress their dissatisfaction,
usually they are not completely successful. These negative feelings “leak out” in
the form of insincere reassurance and support or avoidance and rejection. This
confirms the fears of the depressed spouse that she or he is not accepted, creating
insecurity in their experience of the relationship. Insecurity leads to increased
distress behaviors, which normally elicit caring and concern but in this instance
increase the frustration and guilt in the partner (Coyne, 1976a, 1976b). The result
is a negative interaction cycle which may produce symptoms of depression in the
partner as well (Jeglic et al., 2005).
Coyne’s systemic model of depression is difficult to test empirically and has re-
ceived mixed support. For example, Coyne (1976a) found that undergraduates speak-
ing on the phone with a depressed patient felt themselves more depressed, anxious,
hostile, and rejecting than undergraduates speaking with a nondepressed person.
Other research, however, did not find that husbands of depressed wives had greater
increases of depression or any other mood state during a marital interaction task
(Whisman, Weinstock, & Uebelacker, 2002). Nonetheless, the pattern suggested in
Coyne’s model (1976a, 1976b) can be seen in many couples with depression and is
a useful way to conceptualize couples struggling with depression.

COUPLE THERAPY AS A TREATMENT OF DEPRESSION

There have been at least eight randomized clinical trials of couple therapy in the
treatment of depression although most couple interventions have not been sys-
temic. Two studies employed a partner-assisted intervention where an individual
psychotherapy model was delivered and the spouse attended sessions to support
the patient (Baucom, Shoham, Mueser, Daiuto, & Stickle, 1998). In couples with-
out marital discord, partner-assisted cognitive therapy was equal to individual
cognitive therapy for depressive symptoms (Emanuels-Zuurveen & Emmelkamp,
1997). Individually delivered interpersonal therapy (IPT; Klerman, Weissman,
46 Denton and Burwell

Rounsaville, & Chevron, 1984) was compared to a conjoint form of IPT (Foley,
Rounsaville, Weissman, Sholomaskas, & Chevron, 1989) in couples with marital
problems. Both treatments were equally efficacious for depression, but only the
conjoint form of IPT improved marital functioning.
The remaining six studies applied a conjoint form of therapy in treating depres-
sion, and two of these used behavioral marital therapy (BMT; Jacobson & Margolin,
1979). O’Leary and Beach (1990) assigned 36 maritally distressed couples where
the wife met the criteria for MDD or dysthymia to BMT, individual cognitive
therapy for the wife, or a wait-list control group. At posttest, both treatment con-
ditions were equally superior to the control group. However, only BMT improved
marital satisfaction and these differences were maintained at one-year follow-up
(Beach & O’Leary, 1992). In another study, BMT was compared to individual
cognitive therapy (Jacobson, Fruzzetti, Dobson, Schmaling, & Salusky, 1991) in
a sample of 60 women diagnosed with MDD that contained distressed and
nondistressed couples. Results showed that BMT was less effective than cogni-
tive therapy for depression in the absence of marital discord, but both treatments
were equally efficacious for depression in the presence of marital discord. Again,
only BMT had a significant positive impact on relationship satisfaction.
Other investigators have not clearly specified the model of couple therapy
employed, making the results less clinically helpful. Emanuels-Zuurveen and
Emmelkamp (1996) compared individual cognitive/behavioral therapy to a “be-
havioral/communication-focused” couple therapy in patients with depression and
marital distress. Both interventions produced significant and equal improvement
in depressive symptoms. The conjoint therapy produced more improvement in
relationship functioning. Teichman, Bar-El, Shor, Sirota, and Elizur (1995) com-
bined cognitive and family systems orientations in developing cognitive mari-
tal therapy (CMT) and compared CMT to individual cognitive therapy and a
wait-list control group. CMT was more effective than individual cognitive
therapy for depressive symptoms. However, the individual cognitive therapy
delivered was not more effective than the control group, which raises concerns
about the quality of the individual therapy. Marital satisfaction was not assessed.
There has been one randomized clinical trial where antidepressant medication
was compared to an unspecified form of couple therapy (Leff et al., 2000). Both
groups produced an improvement in scores on the Beck Depression Inventory
(Beck, Ward, Mendelson, Mock, & Erbaugh, 1961), with the couple therapy
group making significantly greater gains than the medication group. This ad-
vantage of couple therapy remained statistically significant at two-year follow-
up. Finally, Emotion Focused Therapy (EFT) for couples (Johnson, 2004) was
compared to antidepressant medication in 12 women with relationship discord
Depression in Couples 47

and MDD. After four months both treatments produced significant and equal
improvement. At six-month follow-up women from the EFT group had made
statistically significant improvement compared to post-treatment (Dessaulles,
Johnson, & Denton, 2003). Women in the medication group did not improve
further, but they had not continued with medication.
All of these studies were with heterosexual couples who were usually, but not
always, married. To our knowledge, there have been no randomized clinical tri-
als of couple therapy in the treatment of depression that included same-sex couples.
Additionally, most of the studies did not report on the ethnicity of the study par-
ticipants, so the implications of culture and ethnicity on the results obtained re-
main largely unknown.
To summarize, couple therapy has been found as effective in treating depres-
sion as individual therapy if the couple has relationship distress, but only couple
therapy improves relationship functioning. Two studies found couple therapy more
beneficial in some ways than antidepressant medication (Dessaulles et al., 2003;
Leff et al., 2000). The only situation where couple therapy was less effective than
individual therapy was for couples with depression and no relationship distress
(Jacobson et al., 1991).

THE EXPERIENCE OF DEPRESSION IN RELATIONSHIPS

Clinical Observations and Conversations with Women

with MDD and Their Partners
In our clinical work we have observed the experience of depression in couple
relationships which have been supplemented by conversations with clients attend-
ing a medical family therapy training clinic. These conversations were examined
informally as part of a larger funded intervention study of couple therapy in the
treatment of women with depression. We specifically asked women with MDD
and their spouses about their relational experience of depression. Thus, most of
the following information pertains to couples where a female partner is experi-
encing depression. The focus on women is not completely unlike the typical clinical
encounter, as MDD is diagnosed more often in women than in men (Kessler
et al., 2003) and men are less likely to seek professional help for depression than
women (Moller-Leimkuhler, 2002). Nonetheless, we acknowledge that MDD is
also a serious problem among men, and more research and couple-specific inter-
ventions are needed in this area. We also note that the following observations are
primarily clinical and anecdotal.
48 Denton and Burwell

Our observations have been that in couples where the female partner has de-
pression, certain roles become established or exacerbated by a depressive episode.
The nondepressed spouse (husband) became protective of the depressed spouse
(wife), who was perceived as more dependent as a result of having more needs.
For instance, some women were not able to fulfill their responsibilities at work or
at home and needed their partner to compensate. Husbands typically took on more
responsibility by handling family issues (e.g., parenting and intercepting phone
calls from other family members). As a result of the shifting of responsibilities
and roles, women described feeling “like a child” and expressed some resentment
toward their husbands who became more like a “parent” or “protector.”
Women often talked about feeling disrespected or controlled by their husbands
in the role of “child,” which fostered a feeling of disconnection from the family.
Some women described that their husbands hovered over them, creating a feeling
of overprotection. Depression also appeared to undermine the authority of women
in the family and impeded their autonomy. However, the women did not want to
be treated like children; they needed their husbands to try to understand what they
were going through emotionally and to be given an opportunity to express their
experience of depression without their husbands’ trying to “fix” them, the depres-
sion, or whatever issue was pertinent. In addition to emotional support, women
also described needing to be soothed; to be reassured that things would get better,
that their husbands would be there for them, and that they would get through the
episode together.
Upon further exploration, we learned that some husbands took on the role of
protector because they secretly feared that their wife might commit suicide, even
in cases where no previous attempt had been made. Despite this fear, suicide
was not discussed openly in the marriage. It seemed to be the “elephant in the
room,” and some men experienced relief after bringing up the topic of suicide,
while others wanted to avoid such discussions. Many men described feelings of
inadequacy because they were not able to understand the illness (particularly
suicidal ideation) and to make the depression go away. In cases where women
attempted suicide, husbands felt they could not trust their wives to refrain from
making another attempt. In these cases, the roles of protector and child were
strongly reinforced.
The final notable commonality in these couples was shame related to the stigma
of having depression. Both wives and husbands felt that it was difficult to discuss
depression with other family members and sometimes with health care providers.
Suicide was viewed as an especially taboo topic for discussion. Women feared that
they would be hospitalized and that others would think that they were “crazy,” fur-
ther undermining their power in the family and credibility with health care profes-
Depression in Couples 49

sionals. Husbands felt that they could not discuss their wife’s depression with any-
one and felt isolated, uninformed, and unsupported. While husbands had been in-
strumental in getting their wife to appointments with her health care provider(s),
the husbands were not part of the treatment for depression. This seemed confus-
ing and frustrating to the husbands and further reinforced that discussing depres-
sion was taboo. Husbands wanted more information about symptoms of depression,
suicidality, and what they could do to help their wives. Husbands and wives wanted
to know how to talk to their children about depression and wanted more informa-
tion about medications that they were taking and their side effects.

Men and Depression

When men present for treatment, they are often more willing to acknowledge
somatic symptoms of depression including fatigue, irritability, loss of interests,
and trouble with sleep than feelings of sadness (Cochran & Rabinowitz, 2000).
There is some evidence that men use numbing and avoiding techniques to cope
with feelings of depression and that gender differences in presentation may not
be due to the experience of depression as its expression (Brownhill, Wilhelm,
Barclay, & Schmied, 2005). Thus, depression in couples may present differently
when it is a male partner that is depressed but the systemic therapist will still seek
to identify how depression fits into a couple’s pattern of interaction.

INTERVENTION STRATEGIES

Attachment-Based Intervention Strategies

We noticed that attachment fears, particularly abandonment, were evident in
these couples. Women were afraid that depression would frustrate their husbands
to the point of giving up and eventually abandoning the relationship. Husbands
discussed feeling alone during their wives’ depressive episodes and had con-
cerns about suicidality, a major abandonment threat. Sometimes this led to over-
protection (e.g., clinging and hovering) and other times it led to withdrawal, both
attachment-activated behaviors, contributing to a demand-withdraw pattern of
interaction.
Couple therapy is well suited to address attachment behaviors that perpetuate
the demand-withdraw pattern of interaction. Promoting secure attachment and
behaviors in couples is a major goal of EFT which is partially derived from at-
tachment theory (Johnson, 2004). Using the framework of attachment theory
50 Denton and Burwell

(Bowlby, 1969), EFT similarly assumes that individuals are connected through
attachment bonds and that much of relationship distress can be understood as at-
tachment distress (Johnson & Denton, 2002). EFT is a synthesis of family sys-
tems and experiential approaches to psychotherapy and has been summarized as
“a focus on the circular cycles of interaction between people, as well as on the
emotional experiences of each partner during the different steps of the cycle”
(Johnson & Denton, 2002, pp. 223–224). The goal of the treatment is to change
negative interaction cycles that couples adopt as a result of attachment distress
and to help them strengthen their attachment bond.
EFT can be used to connect depressive symptoms to the cycle of distress oc-
curring in the relationship and to see how the pattern of interaction maintains and
reinforces the depression. A particularly useful question to pose to couples is, “Tell
me about what happened in your relationship the last time you noticed a depres-
sive episode.” Understanding the experiences of each partner is necessary to iden-
tify the pattern of interaction and the roles and behaviors that each person brings
to the interaction.

Other Intervention Strategies for Couple Therapists

It is also helpful to have each partner identify triggers (e.g., behaviors, words,
feelings, thoughts, events) that preceded the depressive episode. Understanding
and becoming aware of triggers of depression can enable the couple to respond to
them. If depression is triggered by some aspect of the relationship, then an anti-
dote could be to assert one’s hurts and needs and have an attachment figure, or
partner, respond.
Women often wanted to feel emotionally supported by their husbands versus
controlled or parented. One strategy is to dissuade husbands from trying to “fix”
the depression and teach husbands to listen and provide support. This could also
be helpful in relieving men from feelings of inadequacy from not being able to
alleviate the depression. In addition to providing support, guiding each partner to
turn to each other for comfort and reassurance is important in changing the pat-
tern of interaction. Each partner can learn and practice other ways of responding
to each other in a way that will address their attachment needs.
A psychoeducational component may complement couple therapy by provid-
ing specific information about depression and its symptoms. Collaboration with a
psychiatrist or primary care physician may be helpful to discuss potential side
effects of medication. A safety plan should be developed in the event of suicidal
ideation. This plan, in writing, can alleviate anxiety by providing a tangible re-
source to the couple. Collaboration with the health care provider may be a neces-
Depression in Couples 51

sary part of the safety plan, especially if part of the plan is to call the health care
provider.
Therapists can also assist couples “in renegotiating their relationship to deal
more effectively with the problems posed by depression” (Coyne & Benazon, 2001,
pp. 36–37). For example, couples can be assisted in renegotiating a “limited sick
role” (Coyne & Benazon, 2001) for the depressed partner to promote more bal-
ance. That is, the partner without depression may temporarily assume more du-
ties and responsibilities during the depressive episode, but the depressed partner
should not be completely stripped of her or his role and responsibilities. This may
be a helpful strategy in alleviating the “child-protector” dynamic.

CASE EXAMPLE OF SYSTEMIC TREATMENT

OF DEPRESSION USING EFT

We have used EFT in the treatment of depression with a variety of couples from
diverse racial and ethnic backgrounds, various age groups and economic statuses,
and different sexual orientations. Previously we have found that the clients in our
training clinic who gained the most benefit from EFT had lower income and edu-
cation and lower levels of interpersonal cognitive complexity (Denton, Burleson,
Clark, Rodriguez, & Hobbs, 2000). Following is a case example of the use of EFT
in the treatment of depression.

The Couple’s Experience

Jeremy and Nicole met when they were in graduate school. Nicole experienced a
serious episode of depression after college resulting in a psychiatric hospitalization
due to strong suicidal feelings and had been on antidepressant medications since
that time. After the birth of their first child, Nicole began re-experiencing depres-
sive symptoms which promptly resolved after adjustment of her antidepressant medi-
cation. Three years later their second child was born, and Nicole again had an increase
in depressive symptoms. This time, however, the symptoms did not respond as readily
to adjustments in antidepressant medication. While Nicole did feel better after sev-
eral months, her depressive symptoms did not completely subside. It was decided
that she would end her employment outside the home so that she could be at home
full-time with the couple’s two children and because Nicole found it difficult to keep
up with the demands of her job due to her lingering symptoms of depression.
The couple found themselves settling into a pattern where Nicole would have
flare-ups of depression followed by periods where she felt better but never com-
52 Denton and Burwell

pletely without depressive symptoms. The periods of exacerbated depressive

symptoms were increasing in frequency despite continual medication changes
and adjustments, which was frustrating to both spouses. They found themselves
arguing and feeling increasingly distant from each other. Nicole was seeing a
psychiatrist throughout these years, but these visits were focused on medica-
tion adjustments rather than formal psychotherapy. When she began express-
ing her concerns about her marriage, the psychiatrist referred her to a couple
therapist.
The couple therapist identified that both spouses were still committed to the rela-
tionship and still had positive feelings for each other but that there was a high level
of tension in the home. The first session was largely devoted to the couple relating
the history of their relationship and their own experiences of Nicole’s depression.
Over the second and third sessions the therapist was able to identify a negative in-
teraction cycle and, consistent with the EFT model (Johnson, 2004), the therapist
began identifying underlying emotions that the couple was experiencing.
The therapist found that when Nicole was feeling more depressed, it was diffi-
cult for her to accomplish her usual tasks due to low energy, loss of motivation, and
poor concentration. All she felt like doing was taking to her bed, and Jeremy found
these episodes very frustrating. He related that when he felt down he would push
himself to keep going and he thought this approach should be helpful to Nicole.
During the times that Nicole stayed in bed, he would offer suggestions as to what
she might do to feel better, but Nicole did not find these suggestions helpful, as she
lacked the energy to carry them out. Instead, she felt judged by Jeremy and that she
was disappointing him, leading to increased feelings of depression. Jeremy would
become frustrated and eventually “gave up.” Nicole was somewhat relieved once
he gave up, but they both felt isolated and unsupported.

Therapy Strategies
Starting from the second session, the therapist began pointing out the negative
cycle of interaction, highlighting feelings of isolation and lack of support. The
cycle and depression were externalized as the problem, rather than Nicole or Jer-
emy being the problem (White, 1984). This reframe provided relief as Nicole and
Jeremy began feeling that they were fighting a common enemy rather than each
other. The therapist encouraged the possibility that they could be more attached
with statements such as, “You both end up longing for the support and comfort of
the other” (Johnson et al., 2005, pp. 87–88).
As therapy proceeded, Jeremy began to uncover and identify underlying emo-
tions and his own attachment needs. He had trouble putting this into words and the
Depression in Couples 53

therapist helped him voice his experience. Jeremy related that in his work he was an
expert at solving problems and he found he was not able to “solve” depression for
Nicole. This led to feelings of failure which added to his avoidance of her. Nicole
uncovered and expressed her fear that Jeremy would give up completely and aban-
don her. She said she would not blame him for leaving and wondered why he had
not done so already. Jeremy was able to express that when the depression was se-
vere, he was afraid Nicole would never “come back” (i.e., recover).
Eventually, Jeremy was able to talk about the pressure he felt to keep the house-
hold going. He was having trouble sleeping and was more irritable with his office
staff. This was surprising for Nicole, as Jeremy seemed like a “superman” to her.
As Jeremy began talking about needing Nicole’s support, Nicole felt that she had
something to offer the relationship. Over the course of several sessions, Nicole
was able to directly tell Jeremy that his suggestions and advice were not helpful
and actually made her feel as though he disapproved of her. She was able to re-
quest support such as Jeremy’s simply being with her or holding her. This feed-
back was initially difficult for Jeremy to hear and he responded defensively. Again,
over the course of several sessions he became less defensive and able to hear her
and began providing the type of support that she requested. He realized that he
did not have to “solve” her feelings of depression and was surprised to experi-
ence a great sense of relief.
By the end of a course of treatment lasting 17 sessions, Nicole experienced a
significantly greater sense of support and comfort from Jeremy. She continued to
take antidepressant medication, but her mood was significantly improved and more
stable than it had been before the couple therapy. She began to think about seek-
ing employment outside the home again. Jeremy felt satisfaction knowing that he
was providing Nicole the type of support she needed and in a way he would not
have envisioned himself being able to do in the past. He was sleeping better and
was less irritable at work. The couple reached a point where they felt they were
managing life comfortably on their own, and therapy ended with an open invita-
tion to return if needed in the future. The use of the EFT model helped the thera-
pist stay focused on the systemic cycle of interaction between the couple, their
underlying emotions, and their unmet attachment needs as the therapist worked
with them to reconnect and strengthen their attachment bond. In the process, their
relationship became a buffer against depression.

Limitations
While we have found EFT to be applicable to a variety of clients, an important
contraindication of using EFT is domestic violence (Johnson, 2004). Addition-
54 Denton and Burwell

ally, if one or both partners are emotionally fragile (e.g., suicidal ideation), it is
necessary to proceed at a slower pace (Johnson, 2002). Finally, our comments
primarily apply to depression in women, as this has been the focus of our work to
date. Further investigation is needed to determine the extent to which these find-
ings apply to depression in men.
Other general limitations of the research on relationship discord and depres-
sion include that most of this research has focused on heterosexual couples with
almost no attention paid to same-sex couples.

SYSTEMIC COUPLE THERAPY: AN UNTAPPED RESOURCE

Depression is a relatively common and potentially life-threatening problem for

which intimate couple relationships are very relevant. While numerous treatments
are available which have some efficacy, there is a continued need to improve
outcomes in the treatment of depression (Rubinow, 2006). Systemic couple therapy
has much to offer in the treatment of depression and is a largely untapped resource
when considered from a health services perspective. Couple therapists are uniquely
positioned to participate collaboratively with other providers in the provision of
systemic treatment for couples facing depression.

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