Dialogical and Narrative Processes in Couple Therapy for Depression
Condition: Depression
MeSH terms: Depression; Depressive Disorder
Study type: Interventional
Phase: Phase 2/Phase 3

Summary: 
      The main aim of the project is to develop couple therapy for depression with special interest
      in dialogical and narrative processes in therapy. Parenthood, and different psychosocial
      phenomena, such as domestic violence, suicidal behaviour and alcohol abuse in relation to the
      client's specific depressive state will be analysed. The second main aim of the study is to
      analyse the effectiveness couple therapy for depression as a real world study. The good and
      poor outcome of different therapy processes will be compared and thus information about
      precise change processes will be reached. Owing to the real world setting, the inclusion
      criterion is a broad one: a primary diagnosis of depression (F32 and F33 in ICD-10).

      The project will be conducted as a multicentre study so that in each centre the included
      patients will be randomized into experiment and control groups. The study centres are (1)
      Pohjois-Savon sairaanhoitopiiri in Kuopio, (2) Länsi-Pohjan sairaanhoitopiiri in Tornio and
      Kemi and (3) HUS/ Jorvin sairaala regional psychiatric polyclinics in Espoo. In each province
      the entire adult population has free access to the psychiatric outpatient clinics in their
      specific catchment area and thus no selection for the patients is done.
    

Detailed description: 
      In each of these research centres qualified family therapists will conduct the couple therapy
      in case of depressed patients in a team of two therapists. To be a responsible therapist in
      this study the minimum criterion is three years specialist- level family therapy training and
      thus a qualification as psychotherapist according to Finnish law. The therapist shall have
      special experience and interest in dialogical and narrative processes in therapy. All the
      family therapists will also have taken a training program that focuses on systemic family
      therapy, narrative therapies and open dialogue in a family setting. No special therapy manual
      has been written, but the treatment processes will be analyzed after the therapy in relation
      to the outcome. The treatment processes are expected to last for as long as required
      according to the specific needs of each couple. This will allow for the focus on external
      validity: Clients will be recruited in the course of daily clinical practice without any
      selection outside the diagnosis and the therapies are taking place for as long as needed. The
      analyses of the treatment processes in relation to outcome, has termed as progress research
      by Pinsof & Wynne (2000)

      In couple therapy some guidelines are followed. Since every family therapist has training in
      systemic therapy, the therapy can be termed as systemic couple therapy with a special focus
      on dialogues and narratives. The two therapists and the couple form a system in which the
      first aim is to generate dialogue to increase understanding of couple's situation and the
      role of depression in their lives. To this end, spouses are encouraged to speak of subjects
      that they find most important. While one person is speaking, the other three take a
      reflective position in their inner dialogues and afterwards describe their thoughts about
      what was said. The shift between the speaking and listening positions in the topics that the
      couple choose is the basic element in each therapy process. In these processes a new joint
      language is created for experiences without words or experiences manifested in symptoms,
      marital problems or in problematic behaviour.

      Three types of analysis will be conducted:

        1. The effectiveness of systemic couple therapy will be analyzed by (a) the assessment of
           depression by the Hamilton Depression Rating Scale inventory and the BDI and SCL
           self-report ratings scales; (b) the assessment of couple satisfaction by the Dyadic
           Adjustment Scale (DAS) self-report rating scale; and (c) the assessment of the
           psychological status of the patient by GAF rating. In addition to these, (e) domestic
           violence, use of alcohol and other psychosocial factors will be analyzed in interviews.
           Assessments will be conducted before the outset of the treatment, after 6 months, after
           12 months and after 18 months from the beginning of the treatment. Changes in the scales
           between experiment and control groups will be compared. Because of the small size of the
           experimental group and the naturalistic design, no noteworthy differences in the results
           are expected as such. To test hypothetical explanatory power a prove was conducted. In
           the power calculation, a hypothetical sample of 35 received the value .82 in cases where
           the mean difference between two measurements divided by the corresponding standard
           deviation was 0.6. Similarly, if the difference in the means between two measurements
           was 0.5, the explanatory power was .66. Differences that are strong enough cannot be
           expected if only the group differences in the mean values between two measurements are
           analyzed without relating the results to the therapy processes (point 2) and to the
           processes of change (point 3). The explanatory power may be higher, however, after the
           Swedish study site has been added to the sample. The entire sample size would then
           consist of about 55 patients in each group.

        2. Treatment processes will be studied by analysing (a) video or audio recordings of the
           dialogues and (b) the entire treatment processes in a specific follow-up interview three
           months after termination of the couple therapy. This interview will be organized as a
           learning forum, that is, the follow-up interviews will be conducted in a way that
           enables the therapists to evaluate their work together with the couple and an outsider
           interviewer. The aim is at developing the family therapists' therapeutic skills.
           Reflective processes and learning on the part of the families are essential in this
           co-research practice (Andersen 2006). The family and all staff members included in the
           specific treatment process will be invited to this interview. First the therapy team
           will be interviewed about their experiences of the treatment, and then the family
           members will be interviewed about their experiences of the therapy and about their
           thoughts regarding the therapists' experiences. The aim of this interview is to gain
           information about the specific processes through which clients can perform their own
           psychological work with their problems.

        3. Processes of changes will be studied by conducting (a) a Outcome Ratings Scale among
           clients before each session and a Session Rating Scale among both clients and therapists
           after each therapy session and; and by (b) analyzing the qualities of the couple
           therapies by Psychotherapy Q-Sort (PQS) categories (Jones & Jones, 1985). In the PQS 100
           characteristics in 9 categories will be analyzed for one therapy session. The
           characteristics describe 1) attitude, behaviour and explicative experience of the
           patient; 2) actions and attitudes of the therapists; and 3) the nature of the
           therapeutic relationship, environment and atmosphere of the session (Sirigatti, 2004).
           Although the PQS has mostly been used in analysing manualized psychotherapies (Ablon &
           Jones, 2002), implications has recently been developed for non-prescriptive therapies
           (Ablon et al., 2005) and systemic therapy (Sirigatti, 2004). Both analyses will be
           related to the outcome of the couple therapies and thus systematic information will be
           obtained as to which type of dialogues are connected with good outcomes.

      Control group is formed in each of the three centres. These clients will not have family
      therapy sessions during the first 12 months; instead, according to the manner usual in each
      centre they will visit a psychiatrist or other therapists. Clients will be randomly assigned
      to the experimental and control groups after the doctor admitting them has assessed their
      inclusion by diagnosis and the Hamilton Rating Scale and after the first research interview
      has been conducted.

      The inclusion period started in February 2006 and lasted until summer 2007. The first
      follow-up interviews will continue until the end of 2009. In this specific project the
      analysis of the data will begin in 2007 and continue to the end of 2010 concerning this
      specific project. Thereafter the data will be available for post graduate and doctoral
      students under the supervision of the principal investigators.

      Department of Psychology at the University of Jyväskylä is the study site, in which all the
      data will be gathered. In each centre the research data will be stored outside of patient
      records. Information of the ratings scales can be added to specific patient records.
    

Intervention name(s): Psychotherapy
Intervention type(s): Behavioral
Intervention description(s): Narrative and dialogical approach for couples
Allocation: Randomized
Intervention model: Single Group Assignment
Masking: Single (Investigator)
Primary purpose: Treatment
Keywords: Depression; family therapy; dialogical processes; Developing couple therapy for depression