Several couples commented that they had found their participation in this study helpful or therapeutic. In particular, the joint interview format was popular with most depressed persons and partners, who were glad of the opportunity to share their respective experiences in the presence of a sympathetic third party. In most cases, people felt that they had developed greater mutual understanding following their participation in this study and considered that it had been beneficial to reflect on both the trials and tribulations of the support process. Indeed, several couples commented that they had not previously shared their experiences or thought about the helping process in quite this kind of way. Participants also found it helpful to receive a written summary of the views and experiences they had described in the first interview. The possibility that research may be experienced as therapeutic by participants has been commented on by authors writing from a community psychology perspective (e.g. Kelly, 1986). It may therefore be worth considering how the procedure followed in this study could be developed into an intervention for couples in
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which one member suffers from depression. Given that depression is, for most people, a chronic, relapsing condition, it could be that an intervention along similar lines to the procedure described for this study would be most appropriate for persons who are currently out of episode or experiencing relatively mild depressive symptoms. The exchange of information involved could help couples to identify the support strategies that had been most helpful in the context of their relationship, be aware of less helpful approaches, and thus be better equipped to work together in managing future or more severe episodes.
Intervening in this way with couples who are not currently in crisis may help to reduce the sense of struggling alone that was conveyed by several participants. It could also provide an opportunity to ensure that couples receive basic information about depression and details of local services: it was striking how often participants commented that such information had not been forthcoming without considerable effort on their part.
The focus of this study has been on how ordinary people try to help one another in times of psychological distress. To end, however, I would like briefly to consider how the study’s findings might be relevant to formal interventions for depression. The National Institute of Mental Health Collaborative Depression Study reported recovery rates of 57% for antidepressant medication plus clinical management, 55% for interpersonal psychotherapy, and 51% for cognitive-behaviour therapy (Elkin, Shea, Watkins, Imber, Sotsky et a l, 1989). It has been suggested that the sizeable proportion of persons who do not appear to benefit in each case might reflect the fact that such treatments for depression generally focus on working with the individual and do not seek the involvement of persons from his or her ongoing interpersonal environment (Cordova & Gee, 2001). Moreover, most standardised couples therapies for depression treat depression by targeting marital distress (e.g. behavioural marital therapy, cognitive marital therapy, conjoint marital interpersonal therapy). Research into the effectiveness of marital therapy for depression (e.g. Beach & O’Leary, 1992; Foley, Rounsaville, Weissman, Sholomaskas, & Chevron, 1989; Teichman,
Bar-El, Shor, Sirota, & Elizur, 1995) has consistently shown that, while as good as or better than cognitive therapy when the depressed person is also maritally distressed, such interventions are much less effective in the absence of marital distress. Addressing this issue, Cordova and Gee (2001) describe a form of couples therapy for depression (CTD) which can be used to increase support and cohesion in both distressed and non-distressed couples. The principles of this approach, as described for treating non-distressed couples, bear striking similarities with the current study’s findings on how couples worked together. Thus, fundamental to the CTD approach is encouraging the couple to adopt a common perspective towards the depression, which is seen as a shared problem rather than the sole responsibility or fault of either party. To this end, Cordova and Gee refer to fostering:
a sense of ‘we-ness’ ... in which the couple feels united in the struggle with depression rather than divided by i t ... We-ness provides a sense of being able to work together effectively and facilitates both partners taking an active role in addressing their common enemy (Cordova & Gee, 2001, p. 193).
Certain other components of CTD also resonate with the findings of the current study; for example, acceptance of aspects of the relationship that may not be amenable to change (e.g. the depressed person’s ongoing vulnerability to further depressive episodes), increasing behavioural flexibility (e.g. by encouraging mutually empathie and supportive responding), and increasing the effective handling of aversive situations (e.g. through collaborative problem solving). CTD also emphasises the importance, for both members of the couple, of being able to tolerate depressive symptoms at some level. Preparation for relapse is a further component of CTD, enabling couples to prepare emotionally for the possibility of future depressive episodes, develop awareness of potential triggers, recognise warning signs, and prepare effective coping responses. Based on behavioural theories of depression and relationship distress, Cordova and Gee’s CTD has not yet been empirically tested. Similarities between certain key elements of this approach and the current study’s findings
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in respect of how better functioning couples coped with depression seem promising, however.
Previous research suggests that most people with psychological problems prefer to seek the support of helpers in their natural networks. Moreover, there is no reason to suppose that informal helping stops when people take their difficulties to mental health professionals; indeed, it has been argued that seeing a therapist may increase a person’s propensity to discuss aspects of his or her internal world with others (Barker & Pistrang, 2002). Surprisingly, however, informal helping for psychological problems has been neglected in the research literature. The current study has started to explore this area, focusing specifically on the experience of giving and receiving support for depression in the context of an intimate relationship. This study has suggested a number of ways in which partners can be helpful to people with depression and has also called attention to the difficult circumstances in which support for depression is provided. Taken with the findings of previous research indicating that satisfaction with the help received from a partner is an important determinant of overall relationship satisfaction (e.g. Barker & Lemle, 1984) and relationship maintenance (e.g. Pasch & Bradbury, 1998), the picture revealed here suggests that professional helpers should be mindful of the fact that their interventions occur in a wider helping context which often includes the efforts of intimate others. Moreover, couples and family therapists should perhaps be encouraged to show as great a willingness to intervene in cases of miscarried informal helping as shown in relation to interpersonal conflict. Finally, it should not be forgotten that many people facing psychological difficulties are not in intimate relationships. It is therefore important also to consider the nature and impact of informal support in other kinds of relationships in thinking about the needs of people seeking help.