Nathen's Miraculous Escape

Abstract

This paper a brief overview of the evidence and discourse about depression, focusing on its occurrence, dynamics, and treatment in couple relationships.  This is followed by an introduction to Breunlin, Schwartz, and Mac Kune-Karrer’s metaframeworks model for therapy and its possible application in the treatment of depression in couples.

Keywords: depression, couples, couples therapy, metaframeworks

Depression in Couples:

Literature Review and a Metaframeworks Approach

In the last few decades, depression has become an obsession in the US.  We are flooded with ideas about depression from television shows, magazine articles, self-help books, celebrity therapists, theoretical articles, feminist treatises, pharmaceutical advertisements and press releases, research results from biological, clinical, epidemiological, psychological, and sociological perspectives, plus critiques and meta-analyses of that research.  This obsession is not surprising, considering the medical, mortality, and employment costs of the condition are well above $80 billion per year and climbing (Greenburg, Kessler, Birnbaum, Leong, Berglund, & Corey-Lisle, 2003), considering the evidence that prevalence rates are increasing and age of onset is decreasing with each generational cohort (Craighead, 2007), and considering what an unpleasant and dangerous condition it is.  The World Health Organization has predicted that in the next 15 years depression will move from the fourth most disabling disease in the world to the second, behind only obesity/diabetes (Sapolsky, 2009).

In my practice as a couples and family therapist in training, depression is just as common a complaint as the ubiquitous “communication problems,” meaning at least one partner in every couple I have seen so far has considered themselves clinically depressed.  This paper represents my attempt to delve into the data and conversation about depression, how it is treated in couples, and to approach it using the perspective of metaframeworks, as put forth in Breunlin, Schwartz, and Mac Kune-Karrer’s (1997) Metaframeworks: Transcending the Models of Family Therapy.

Depression

What Do We Know About Depression?

We know how we define it. In the mental health profession, if someone “has depression,” we mean that they meet the criteria in the current edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) for Major Depressive Disorder.  That means the daily presence of a depressed mood, anhedonia, and at least three of the following six symptoms for at least two weeks: (a) weight loss or gain of at least 5%, (b) insomnia or hypersomnia, (c) observable agitation or slowed movement, (d) fatigue, (e) feelings of guilt or worthlessness, (f) subjectively or objectively decreased cognitive ability, and (g) suicidality. Additionally, these symptoms must  impair functioning in some significant way, must not be the result of an illness or drug, and must not be the result of bereavement—that is, must not occur only within two months of the loss of a loved one (American Psychiatric Association [DSM-IV-TR], 2000).

Additionally, we define depression in terms of the number of depression-indicating responses to surveys, like the Hamilton Rating Scale for Depression (HRSD) (Hamilton, 1980) and the Beck Depression Inventory (BDI-II) (Beck, Steer, Ball, & Ranieri, 1996).  The HRSD and BDI have participants rate symptoms, mostly DSM-IV-TR criteria, on Likert scales between none and severe.  They produce numbers which are compared to predefined cutoffs for no, mild, moderate, severe, and (for the HRSD) very severe depression.

We know quite a few correlates. Depression is associated with intense affect, especially sadness and anxiety, as well as physical pain, addiction, suicide, and social problems such as divorce, unemployment, and truancy (DSM-IV-TR, 2000).  It is also correlated with internal attributions of negative events and external attributions of positive events (Pinto & Francis, 1993).  Of the 17% of US residents who qualify as depressed at some point in their lives, between 10.5 and 18 million people at any one time, two-thirds are female (Craighead, Sheets, Brosse, & Ilardi, 2007), though the DSM-IV-TR reports that rates are even between boys and girls before puberty. The DSM-IV-TR also claims that there are no difference between those in different ethnic, socioeconomic, educational, or marital categories (DSM-IV-TR, 2000), though there is some evidence for a correlation with poverty (Kim, 2008; Vilhjalmsson, 1993) and menial labor (Bonde, 2008).

Major childhood stressors such as physical, emotional, and sexual abuse, witnessing domestic violence, separation, or divorce, or drug abuse, criminal activity, mental illness, or suicide in the household significantly increase rates of depression in adults (Anda, Whitfield, Felitti, Chapman, Edwards, Dube, & Williamson, 2002; Chapman, Anda, Felitti, Dube, Edwards, & Whitfield, 2004; Edwards, Holden, Anda, & Felitti, 2003).  Major stressors in adulthood, especially those related to social rejection, can also precipitate depression (Kendler, 2003; Kessler, 1997; Slavich, Thornton, Torres, Monroe, & Gotlib, 2009).  The highly religious appear to be more prone to depression, though more resilient against it once it occurs (Dein, 2006; McCullough & Larson, 1999).  Depression is more common among  people with major medical conditions (DSM-IV-TR, 2000).

There are no biological tests for depression (DSM-IV-TR, 2000).  There do appear to be a few biological correlates, however, including atrophy of the hypothalamus (Patterson, Albala, McCahill, & Edwards, 2010), increased stress-hormone levels, decreased growth-hormone levels (DSM-IV-TR, 2000), and a short allele of the  5-HTT gene (Caspi, Sugden, Moffitt, Taylor, Craig, Harrington, McClay, Mill, Martin, Braithwaite, & Poulton, 2003).  Being related to a person with depression increases your chances of becoming depressed as well, which is suggestive of a biological correlate (DSM-IV-TR, 2000).  Each of these factors correlate to a significant degree with incidence of depression, but none to the extent that they are candidates for a cause.

By far the strongest biological correlation with depression we know of so far are abnormalities in electroencephalogram (EEG) readings during sleep.  The DSM-IV-TR reports a correlation of 40-60% in outpatient groups and up to 90% for inpatients (2000).  Also, complete sleep deprivation has been shown to entirely alleviate symptoms of depression in over half of participants (Wu & Bunney, 1990).

Another category of correlates is treatment outcomes.  These fall into three general categories–therapeutic, somatic, and placebo–most of which are basically equivalent in their efficacy, which is to say they seem to have a lasting positive effect somewhere around half to two-thirds of the time (Patterson et al., 2010).  The evidence that we have about therapeutic treatment comes largely from clinical tests of variants of cognitive and behavioral therapies, and finds these therapies to be effective to the same degree (Wampold, 2001).  In somatic treatments depressed people take medication, have their brains shocked, have their sleep interfered with, or, in the most extreme cases, their brains operated on.  In a placebo treatment depressed people eat sugar pills which they believe might be medication.  There is evidence that some medications work significantly better than placebos for those with severe or very severe depression (Fournier, DeRubeis, Hollon, Dimidjian, Shelton, & Fawcett, 2010).  There is evidence that reducing REM sleep over time can improve symptoms of depression to the same or somewhat better than a placebo (Rieman, Berger, & Voderholzer, 2001), and there is evidence that electroconvulsive therapy (ECT) is the most effective treatment of all, at approximately 80% response rate (Patterson et al., 2010).  There is also evidence that stereotaxic anterior cingulotomy reduces the symptoms of depression (Ballentine, Bouckoms, Thomas, & Giriunas, 1987; Sapolsky, 2009; though see Cohen, Paul, Zawacki, Moser, Sweet, & Wilkinson, 2001).

What Do We Think About Depression and How Do We Treat It?

How we think about and treat depression is shaped greatly by our theoretical perspective; cognitive therapists emphasize the role of thinking  and psychiatrists emphasize the role of neurobiology.  In the face of the evidence, however, very few theorists or clinicians still believe there is a single, causative factor for depression.  Most, instead, believe some version of the diathesis-stress model, which holds that depression is the result of an interaction between biological factors, usually genetic and/or epigenetic, and some form of environmental stress, such as trauma or loss (Monroe & Simons, 1991; Sapolsky, 2009).

That said, each school of thought does think about and treat depression differently.  Psychiatrists and other medical doctors, for example, tend to emphasize the diathesis side, and see depression as primarily a more-or-less mysterious biological disease, caused by a disregulation of neurotransmitters or other hormones, or some other wiring or firing malfunction of our neural networks.  These clinicians prescribe somatic therapies based on their theoretical training.  The vast majority of patients receive medication that is thought to increase the effects of seratonin on the brain (SSRIs), and most of the rest receive one of a couple older classes of medications, thought to act on norepinepherin or on all monoamine neurotransmitters (Olfson, Marcus, Druss, Elinson, Tanielian, & Pincus, 2002; Unutzer, Katon, Callahan, Willians, Hunkeler, Harpole, Hoffing, Penna, Noel, Lin, Tang, & Oishi, 2003).  Somewhere between 8 and 60% receive psychotherapy, depending on their age (older patients get less therapy) (Olfson et al, 2002; Unutzer et al., 2003).  By comparison, other somatic treatments, such as electroconvulsive therapy, vagal-nerve stimulation, REM-deprivation therapy, light therapy, and changes in diet or exercise, are prescribed for only a tiny fraction of patients.

Those operating from the standpoint of a psychotherapeutic modality, on the other hand, tend to focus on the stress side of the diathesis-stress model, and each model has its favorite stressor.  Cognitive therapists, for example, see depression as the result of extreme, inaccurate, and pessimistic thoughts and beliefs, and treat it by helping clients recognize and counteract these distortions (e.g. Beck, 1976; Ellis, 1998).  Behavioral therapists see depression as essentially as a bad habit resulting from environmental rewards for depressive behavior and punishments for non-depressive behaviors, which are best treated by reversing that reinforcement system (e.g. Kanter, Cautilli, Busch, & Baruch, 2005).  The many, many varieties of psychodynamic therapy all have in common the beliefs that problems come from clients’ internal, unconscious conflicts, and that they are best worked out in a conversation with a therapist that leads to insight.  Different schools of psychodynamic therapy each have different emphasis, however, that  affect how they see and treat depression.  A psychoanalyst might see depression as the result of early, formative experiences that caused the client to turn their anger inward into guilt, and ask the client to free-associate and talk about dreams over a period of years, offering periodic interpretations.  Humanistic psychodynamic models such as Rogers’ client-centered therapy, Perls’ Gestalt therapy, and Yalom’s existential therapy focus more on how clients heal, in the present moment, in the presence of a therapist who is behaving authentically, than on how they become troubled.  A client-centered therapist believes that depression is best ameliorated by the client coming to trust the unconditional positive regard of the therapist (e.g. Rogers, 2003).  A Gestalt therapist believes that they can help by challenging the client to behave with complete authenticity (e.g. Perls, 1973).  An existential therapist believes that genuinely coming to grips with the reality and inevitability of suffering and death are the most helpful (e.g. Yalom, 2009).  One psychodynamic approach–psychodynamic-interpersonal therapy–was designed to treat depression.  Like other psychodynamic approaches, it focuses on emotions, interpersonal experiences, and the therapeutic relationship–but it also incorporates Bowlby’s attachment theory and typically uses few enough sessions to be called “brief therapy” (e.g. Klerman, Weissman, Rounsaville, Chevron, & Rounsaville, 1984).

Couples and family therapists have many of their own systemic views of the stress side of the diathesis-stress model.  Confronted with a client complaining of depression, an MRI-style brief therapist, for example, would first look for problematic, outdated rules that the family system is acting under, in the form of their attempted solution for the problem.  They would design an intervention that represented as much as possible the opposite of the family’s attempted solution, perhaps by prescribing depressive behavior (e.g. Fisch, Weakland, & Segal, 1982).  A structural family therapist would imagine that depression is the result of inappropriate power alliances between, for example, a parent and child against a second parent.  They would design a behavioral intervention to realign the family hierarchy, such as advising the parents to go out on a secret date (e.g. Minuchin & Fishman, 1981).  A strategic therapist might also see depression as the result of outdated rules or inappropriate power alliances, but also looks for how the depression might be serving a function for the family system—the interpersonal payoff.  If the latter is suspected, a strategic therapist might prescribe an Ericksonian ordeal, intended to make the problematic behavior more difficult to maintain than non-problematic behavior (e.g. Haley, 1984).

An experiential family therapist would find the depressogenic stress in a client’s low self-esteem, and attempt to remedy it by modeling and by leading communication exercises designed to increase authentic communication (e.g. Satir, 1983).  For a Bowenian intergenerational family therapist, stress is the result of a lack of differentiation, meaning anxiety and rigidity of behavior in response to external or internal emotional pressures.  To help increase a client’s differentiation, a Bowenian therapist explores the quality of extended-family relationships and interrupts emotional triangulation, while maintaining their own differentiation (e.g. Nichols & Schwartz, 2008).

A feminist family therapist looks for and tries to resolve stress in the form of gender- or culture-based power differentials (e.g. Leupnitz, 1988).  A solution-focused family therapist believes that stress is the result of a focus on problems, and attempts to alleviate it by focusing on and enhancing exceptions to the problems (e.g. deShazer, 1988).  A narrative family therapist sees stress as the result of clients having internalized a negative discourse about themselves from the dominant culture, and attempts to alleviate it by finding examples in the client’s life that are contradictory to that discourse and re-author a new story.  Narrative therapists also rely on a technique called externalization, where a client’s problem is given a name and the client comes to see it as not part of their self (e.g. White & Epston, 1990).

Emotionally-focused couple therapy (EFT) finds stress is in unmet attachment needs for safety, proximity, and connection.  Therapy consists of an emotional negotiation of what gets in the way of asking for and responding to requests for attachment needs, especially in relationships with a pursue-distance dynamic (e.g. Johnson, 2004).  In Gottman’s couple therapy, the stress resulting in depression is an internal working model of worthlessness and lack of control, and therapy consists primarily of developing a new story about the self, in conversation, creating new and different kinds of positive interactions (e.g. Gottman, 1999).

One other school of thought about depression does not come along with a therapeutic modality, but is worth mentioning.  Evolutionary theorists have recently suggested that while depression is unpleasant and dangerous, it may be an adaptive behavior.  There is evidence to suggest that depression is essentially a physiological state designed to enhance our analytic-rumination process in the face of complex social problems (Andrews & Thomson, 2009).  In other words, depression may help us concentrate on and think about difficult interpersonal situations.

Depression in Couples—Two Literature Reviews

Social psychologists, apparently spurred on by an insatiable desire to understand the minute details of the relationship between depression and marital distress, have amassed a mountain of evidence, from the obvious to the baffling, about depression in couples and how depression affects couples’ and family’s dynamics.  The simple version of the story is that, while complicated by gender and many other factors, there is a relationship, and it is not good.  Depression in couples is not good for the couple, the individuals in the couple, or the children that come from the couple:

Depression correlates with dysfunctional marital interactions and marital distress (Gabriel, Beach, & Bodenmann 2010; Rehman, Ginting, Karimiha, & Goodnight, 2010), but there is also evidence that it does not contribute in any unique way to a couple’s communication (Eldridge, Jones, Sevier, Clements, Markman, Stanley, Sayers, Sher, & Christiansen, 2007).  Depression is negatively correlated with relationship satisfaction (Cramer & Jowett, 2010) and positively correlated to violent and abusive behaviors in relationships (Vaeth, Ramisetty-Mikler, & Caetano, 2010).  Depression reduces dyadic adjustment (Tilden, Gude, Hoffart, & Sexton, 2010), is less likely to remit in the presence of dyadic discord (Denton, Carmody, Rush, Thase, Trivedi, Arnow, Klein, & Keller, 2010), and predicts low relationship quality (Papp, 2010).  Depression is a precursor to divorce (Doohan, Carrere, & Riggs, 2010).  Depression hinders attachment in couples (Mehta, Cowan, & Cowan, 2009).  Depression in one spouse predicts depression in the other (Goodman & Shippy, 2003) (but not in dating couples (Segrin, 2004)).  Depression in either partner predicts marital dissatisfaction (Whisman, Weinstock, & Uebelacker, 2002).  Depression can trigger relationship problems/marital distress, and relationship problems/marital distress can trigger depression (Reich, 2003; Mead, 2002).  Distressed relationships increase depression relapse (Whisman & Schonbrun, 2010).

There is some evidence about what might help. A sense of enduring control in a relationship, for example, may buffer against depression (Keeton, Perry-Jenkins, & Sayer, 2008), and marital satisfaction is higher whether or not there is depression if your spouse likes you (Sacco & Phares, 2001).  And there is some evidence about how the interactions work.  Evidence exists, for example, that marital discord and depression may be mediated by hopelessness and blame (Sayers, Kohn, Fresco, Bellack, & Sarwer, 2001).  Partners’ depressive symptoms tend to become more similar, which may be driven by their coping styles becoming more similar (Holahan, Moos, Moerkbak, Cronkite, Holahan, & Kenney, 2007).  Depression may cause marital dysfunction and psychological distress by reducing the empathic accuracy of the depressed partner—that is, because they imagine incorrectly that the non-depressed partner feels as badly as they do (Papp, Kouros, & Cummings, 2010)–but there is also evidence that depression does not affect empathic accuracy in couples (Cramer & Jowett, 2010).  It is far more common for people seeking help for depression to have a relationship in distress than for those seeking help for relationship distress to have depression (Atkins, Dimidjian, Bedics, & Christensen, 2009).

Many of the findings are gender-specific. The effects of depression on relationship problems and vice versa are greater for women than men (Reich, 2003).  For women, neuroticism increases the effect of marital distress on depression, but for men it decreases it (Davila, Karney, Hall, & Bradbury, 2003).  Negative marital interactions make women’s but not men’s depression worse if they don’t have confidence in the relationship (Whitton, Olmos-Gallo, Stanley, Prado, Kline, St. Peters, Markman, 2007).  Husbands’ depression predicts wives’ depression, but not vice versa (Kouros & Cummings, 2010).

Finally, there is a lot of evidence that depression in parents is not good for their children, correlating with less secure attachment as infants (Martins & Gaffan, 2000), for example.  Parental depression affects  children’s adjustment to school more than parenting ability does (Cummings, Keller, & Davies, 2005). And depressed parents tend to have more depressed and disabled adult children (Timko, Cronkite, Swindle, Robinson, Turrubiartes, & Moos, 2008).

Treating Depression With Couples Therapy: The Evidence

Most of the research on treating depression with couples therapy has involved behavioral marital therapy (BMT).  I found ten empirical studies looking at BMT for depression.  Five of them compared BMT to individual cognitive or cognitive-behavioral therapies (CT or CBT).  In three of those, BMT was equivalent to individual therapy in its amelioration of depression, but more than individual therapy, it reduced marital discord  (Beach & O’Leary, 1986), increased marital adjustment for depressed women (Beach & O’Leary, 1992), and increased marital satisfaction (Emanuels-Zuuveen & Emmelkamp, 1996).  In the fourth, BMT reduced depression as much as individual CT, but only for distressed couples, not non-distressed couples (Jacobson, Dobson, Fruzzetti, & Schmaling, 1991), and in the fifth, a “behavioral spouse-aided therapy” for depression was equivalent to individual CBT but had no boost for marital satisfaction (Emanuels-Zuurveen & Emmelkamp, 1997).  In a sixth study, BMT reduced wives’ depression significantly more than a wait-list control, with 67% of participants improved and nearly half recovered three months later.  Additionally, wives’ marital satisfaction increased and husbands’ psychological distress decreased (Cohen, O’Leary, & Foran, 2010).  In the seventh study, two-thirds of depressed women improved with BMT, and nearly half recovered (Cohen, O’Leary, & Foran, 2009).  In the eighth, two-thirds of depressed spouses of both genders recovered from depression with BMT (Sher, Baucom, & Larus, 1990).  In a final study, depressive symptoms actually predicted positive outcomes for BMT (Jacobson, Follette, & Pagel, 1986).

Three studies looked at cognitive-oriented approaches.  CBT family therapy for depressed parents significantly alleviated parental depression, but the nearly-large effect size (d = .49) at six months fell to a small-to-medium effect size (d = .26) at a 12-month follow up (Compas, Forehand, Keller, Champion, Rakow, Reeslund, McKee, Fear, Colletti, Hardcastle, Merchant, Roberts, Potts, Garai, Coffelt, Roland, Sterba, & Cole, 2009).  Cognitive marital therapy reduced depression as much as individual cognitive therapy for depression and was a little better for severe depression (Teichman, Bar-El, Shor, Sirota, & Elizur, 1995).  Finally, seven sessions of cognitively-oriented family therapy produced substantial and long-term recovery from depression in depressed female parents and small recovery rates for depressed male parents (Beardslee, Wright, Gladstone, & Forbes, 2007).

Five more studies looked at a variety of other couples treatments.  An “integrative approach,” combining systemic, narrative, cognitive-behavioral therapies and psychoeducation, for residential adults with depression showed improvement with significant and large effect sizes (Tilden, Gude, Sexton, Finset, & Hoffart, 2010).  A “coping-oriented couple therapy” matched CBT and individual interpersonal therapy for improving depression (Gabriel, Bodenmann, Widmer, Charvoz, Schramm, & Hautzinger, 2009).  Systemic couples therapy was at least as effective as drug therapy, and more acceptable to participants (Leff, Vearnals, Brewin, Wolff, Alexander, Asen, Dayson, Jones, Chisholm, & Everitt, 2000).  EFT was also as effective as drug therapy for depression (Dessaulles, Johnson, & Denton, 2003).  A trial that included but did not separate the effects of integrative, systemic, psychodynamic, Gestalt and behavioral therapies reduced depression by about half in couples with infidelity and by a quarter in couples without infidelity (Atkins, Marin, Lo, Klann, & Hahlweg, 2010).

Finally, a meta-analysis in 2008, using seven of the studies mentioned above and ruling many others out for various reasons, found that couples therapy and individual therapy are equally effective treatments for depression and that couples therapy has the additional benefit of relieving distress in couples, but that there is so little evidence and it has been produced and described so poorly that it is too early to recommend couples therapy as a treatment for depression 46 (Barbatto & D’Avanzo, 2008).

Metaframeworks

Metaframeworks is an approach to therapy synthesizing ideas from many different models of family therapy, plus postmodern philosophy, multiculturalism, feminism, and Bateson’s interpretation of Bertalanffy’s general systems theory.  It was developed by family therapists and theorists Breunlin, Schwartz, and Mac Kune-Karrer, and initially presented in their 1992 book, Metaframeworks: Transcending the Models of Family Therapy.  (All information about information presented below about metaframeworks, however, is based on my interpretation of their second, revised, edition of that book, published in 1997.)  Breunlin and colleagues propose that humans suffer as a result of constraints upon their intrinsically resourceful and self-actualizing nature.  These constraints exist on any of several levels of organization: biological, individual, relational, familial, communal, and societal.  Constraints also exist in any of several forms, which give the names to the six metaframeworks: mind or “internal family systems” (IFS), sequences, organization, development, multicultural, and gender.  The level and form that constraints exist on and as interact to form a web of constraints, which can be conceptualized as in Figure 1 (see appendix).  In this conception, clients’ problems can exist as a result of constraints at any combination of points in the web.  The job of the therapist is, in a flexible, collaborative, and intuitive process, identify and release the constraints that are not allowing clients to resolve their problems.

The Role of Systems Theory

Systems theory is a body of thought concerned with “whole” patterns of organization and interaction and the relationships between them.  In metaframeworks, those wholes (called holons) are characterized as a distinct network of parts which interact recursively by a set of organizing rules that allow for both adaptation and stability.  Holons exist and interact both in parallel and in hierarchies. For example, the organs in a human body are each holons, interacting with the other organs in various ways. At the same time, each organ is also interacting with the holons at higher (the whole body and “up”) and lower (individual cells and “down”) levels of organization.  The nature of all of these interactions is said to be recursive, meaning the action of each part of each whole at each level of organization affects the actions of every other part of every other whole, at every other level or organization.
A metaframeworks-oriented therapist uses the lens of systems theory to work towards a rich, holistic view of their clients, and to keep in mind all of the levels of organization that constraints might exist on, and how those levels might interact.  An individual client might be constrained by a biological disease process, for example, or an oppressive economic system.  Additionally, the disease, the person, and the economic system all interact with each other, each one possibly generating, regulating, or supporting the others in different ways.  Without a systemic view, we miss might these interactions and, therefore, possible points of intervention.

Epistemology and Assumptions

A metaframeworks-oriented therapist works grounded by a view of reality, health, human nature, and change based on four assumptions.  First, they take a middle-of-the-road constructivist stance, called perspectivism.  That is, our senses and thinking do produce maps of a reality that exists independently, but our maps are always limited by our perspectives—our senses, beliefs, and cultures.  Furthermore, some maps are more accurate than others.  Second, it is more accurate and useful to think of human problems in terms of constraints than pathology.  That is, if we assume that a client is suffering or dangerous because we have yet to identify and resolve factors that are holding them back from their potential, we are much more likely to help them than if we assume that they are evil or broken.  Third, healthy systems are characterized by balance, harmony, and leadership.  It is the job of certain parts of a system to provide flexible coordination and regulation for that system, and lack thereof indicate that the leadership of the system is acting under constraints.  Likewise, escalation, rigidity, and failures to adapt or meet the needs of some parts of a system are indications of constraint.  Fourth, metaframeworks-oriented therapists believe that intrapsychic work with the subpersonalities of an individual client is often important to resolve constraints.  The rejection of inner work by behaviorists and early family theorists limited the ability of therapists to identify and resolve constraints.  Furthermore, subpersonalities are organized and interact in the same way that parts of other systems are organized and interact:  They are ideally balanced and harmonious, and have strong leadership in the Self, which is similar to Freud’s concept of ego, but they can become polarized, extreme, or rigid and thus constraining.

Using Metaframeworks

Each of the metaframeworks is a perspective from which to look for and at constraints at any level of organization.  Each has its own conceptual framework, vocabulary, and can suggest different hypotheses and interventions.  The metaframeworks approach uses these perspectives with a blueprint for continually and collaboratively expand and fine-tune therapy for each client.

Internal family systems. IFS is a model of therapy as well as a metaframework.  As a metaframework, it is essentially a psychodynamic theory, positing the existence of a Self plus any number of subpersonalities, each filling a specific role.  We may have a creative part, a cautious part, an adventurous part and so on.  IFS holds that trauma can cause a breakdown in the organization of our subpersonalities.  Instead of balanced and harmonious parts lead by a strong self, some parts can become dissociated and others can come to overshadow the Self.  A typical result of trauma is that the Self becomes weak compared to three categories of parts:  exiled parts holding scary, painful memories which can be triggered, manager parts which are vigilant for danger and keep the exiled parts exiled, and firefighter parts which react aggressively if apparent danger or an exile get too close.

As a model of therapy, IFS gently works with the Self of a client to calm and contain the manager and firefighter parts so that the exiled parts can be heard and healed.  When this happens, the Self naturally regains leadership of the intrapsychic system.

Sequences. The sequences metaframework is a way of looking for constraining patterns of behavior at different time increments.  Constraining patterns can exist at the level of individual interactions, such as conversations or arguments, at the level of daily routines, such as work or school schedules, at the level of longer cycles, such as yearly holiday rituals or seasonal production cycles, or at the level of intergenerational patterns, such as inheriting a tendency for abusing people or substances from parents or grandparents.  Breunlin and colleagues also acknowledge the possibility of longer cycles, such as Strauss and Howe’s (1991) four-generation cycle, or even larger societal shifts of values.  The different temporal levels of patterning also interact with each other recursively.  Patterns at any level can exacerbate or ameliorate patterns at any other level.

A metaframeworks-oriented therapist who suspected constraining sequences would choose interventions from models of therapy which specialize in the relevant temporal level of sequence.  Constraints at the level of face-to-face interactions, might best be resolved using techniques from the MRI school of thought, for example, while constraints at the level of intergenerational patterns might be best resolved using Bowenian interventions.  Or if a therapist suspects that one pattern is ameliorating a different, more constraining pattern, solution-focused interventions may be the most appropriate.

Organization. The organization metaframework is used to assess for constraints of balance, harmony, and leadership at various levels of organization.  Balance is a state in which each part of a system has an appropriate amount of resources and power compared to other parts.  Harmony is the presence of cooperation and a balance between autonomy and interconnectedness between parts.  Some parts of a system appropriately provide leadership for that system, regulating the flow of resources, and planning for the future with the health of the whole system in mind.  Parents, for example, appropriately fill this role in nuclear families, and elected leaders in democratic societies.  Weak, rigid, or extreme leadership indicates constraints on a system’s organization.

A metaframeworks-oriented therapist who suspected organizational constraints might choose interventions from models of therapy which specialize in that kind of organizational constraint.  Structural, strategic, and Bowenian family therapies, for example, focus in different ways on the quality of boundaries and leadership in a system which can constrain harmony and balance.

Development. The development metaframework reminds us that there are more or less predictable developmental pathways that each level of organization follow.  It is important to keep the milestones of those paths in mind in order to recognize, normalize, and ameliorate constraints that can appear at each stage of each level: biological, individual, relational, and familial, recognizing a recursive relationship between developments at all levels, including societal.  Breunlin and colleagues use an adaptation of Carter and McGoldrick’s (1988) family life cycle theory for family development, an adaptation of Wynne’s (1988) relational development theory for relationships, and posit a theory of individual development in which people in a transition between more stable stages exhibit an oscillation between behaviors appropriate to the old and new stages.  In the absence of constraints, the oscillation dampens towards the new stage.  An oscillation of competence that is maintained is a clue to the presence of significant constraints.

A metaframeworks-oriented therapist should notice and resolve four types of developmental constraints, promoting synchronous development between all levels of organization:  First, if a family is not adapting flexibly to a new life-cycle stage, they are encouraged to notice and adapt to their new circumstances.  Second, if an individual is exhibiting behavioral oscillations, the therapist collaborates with the family to facilitate age-appropriate competence.  Third, in the presence of a biological constraint to development in an individual, the therapist encourages the family to adjust their expectations appropriately.  Fourth, therapists  help enhance any underdeveloped relationship qualities: attraction, liking, nurturing, coordinating meaning, rule setting, and metarules.

Multicultural. The multicultural metaframework is a perspective for therapists to use which takes into account the cultural diversity present in both our clients and ourselves, and the potential interactions between those cultures.  They include immigration status, economic status, education, ethnicity, religion, gender, age, race, minority/majority status, regional background, sexual orientation, disability, and the presence of marginalizing physical characteristics.

A metaframeworks-oriented therapist uses the multicultural metaframework to generate questions, conversations, and knowledge about how the therapist’s and clients’ diversity affect the experiences we have and the meanings we make of them.  The degree of cultural overlap, or fit, between client and therapist, majority and minority factions, or between immigrant and host cultures is a clue to the possibility of constraints; any area of cultural incongruity is likely to produce constraints on the part with less resources and control.

Gender. The gender metaframework is a systemic feminist perspective on therapy, based on the ideals of egalitarianism between genders and ecofeminism, a philosophy of interrelatedness and compassion between all.  Breunlin and colleagues propose a developmental scheme for gender in relationships from traditional, with patriarchal gender roles, to gender aware, where women begin to become angry and men fearful about power and gender roles, to polarized, where those angry and fearful parts are running the show, to balanced, where an egalitarian organization is idealized by both men and women, who work to achieve it.

A metaframeworks-oriented therapist uses the gender metaframework to highlight and attempt to release clients from the constraints of patriarchy.  The therapist identifies the gender stage a client and/or client system is at, and uses questions, statements, and directives designed to move the client or system toward the balanced, egalitarian stage.

The blueprint for therapy and the role of the therapist. A metaframeworks-oriented therapist aims to find and remove constraints that are holding clients back from flexible adaptation, balance, and harmony, keeping in mind that problems can be generated by a recursively interacting constellation of constraints existing at any level of organization, and in the form of any of the metaframeworks’ domains.  This means that therapy for each client will be unique, addressing their particular constellation.  That unique therapy is accomplished with four recursively interacting processes:  (a) Hypothesizing is taking an educated guess at what relevant constraints exist, taking care to remain curious rather than adamant about the truth of hypotheses.  (b) Planning is collaboratively implementing techniques and interventions from any model of family therapy that the current hypothesis suggests, taking care to tailor those interventions to fit the assumptions of metaframeworks.  Planning includes relating, or maintaining the therapeutic relationship, staging, or keeping an eye on the current position in the therapeutic arc, and creating events, which is the actual implementation of interventions.  (c) Conversing means conducting the therapeutic conversation, using questions, statements, and directives, taking care to use language that does not produce defensiveness or confusion in clients.  (d) Reading feedback is the process of recognizing and distinguishing the importance of what clients do and say, taking care to remember that clients are speaking and we are listening from the standpoint of personally and culturally limited perspectives.

A metaframeworks therapist relates to their clients under two balancing principles.  First, it is the therapist’s job to provide leadership for the process of therapy.  Second, for a true collaboration, the therapist must remain honest and clear about what they are doing, thinking, and why.  Under those principles, the therapist moves intuitively between the four components of therapy, hypothesizing, planning, conversing, and reading feedback, and between the six metaframeworks, mind/IFS, sequences, organization, development, culture, and gender.  Doing so, they are most likely to recognize the relevant constraints and deliver effective interventions in a respectful way.

Evidence and a Rationale for the Use of Metaframeworks

There appears to be very little experimental evidence to date supporting Breunlin and colleagues (1997) theory of therapy specifically.  A PsychInfo search on December 3, 2010 for “metaframeworks” produced, for example, only 15 relevant hits.  Two of those were editions of Breunlin and colleagues’ book (1992; 1997), 5 were theoretical chapters (Breunlin & Mac Kune-Karrer, 2002; Breunlin, Rampage, Eovaldi, Mikesell, 1995; Foy & Breunlin, 2001; Lebow, 2003; Rampage, 1998), 3 theoretical doctoral dissertations (Luther, 1995; Nehring, 1998; Schneider, 1998), 2 theoretical journal articles (Breunlin, 1999; Pinsof, 1992), 1 journal article about a metaframeworks training video (Cohen & Abed, 2003).and 1 book review ( Lawson, 1993).  The only hits purporting empirical evidence about metaframeworks (Oulvey, 2000) admits in the abstract that the research design invalidated any results.

A PsychInfo search for “internal family systems” did little better:  The approximately 20 relevant hits were overwhelmingly theoretical presentations or critiques.  The 3 empirical hits consisted only of case reports.  Two were of a successful treatment of a 17-year old female with bulimia (Schwartz, 1987; Schwartz & Grace, 1989), and the other of an African-American family with a young, female sexual abuse survivor (Wilkins, 2007).

Though this may not represent every piece of empirical evidence supporting the metaframeworks theory of therapy, it is clear that neither its tenets nor effectiveness have any strong empirical support.  While we cannot assert with any certainty what forthcoming evidence will suggest about metaframeworks, we can safely assume that the present dearth of evidence in either direction is a result of the newness of the theory rather than the bias of scientific journals against publishing null results.

A rationale for the use of metaframeworks at this point, therefore, must be primarily theoretical.   Theoretically, the efficacy of a therapist using metaframeworks is likely to fall within the same range as other models of therapy, since all models of therapy that have been tested so far appear to function in approximately the same range (Miller, Duncan & Hubble, 1997).  Why should metaframeworks be different?  There are optimistic and pessimistic views:

An optimist about metaframeworks might say that metaframeworks stands to outperform other models for two reasons. First, the stress in the diathesis-stress model is likely to exist in many different forms, and metaframeworks looks systematically at most of the forms we know about, where other models tend to focus on one or two.  Second, to the extent that the efficacy of therapy relies on model-specific techniques and interventions, famously estimated at 15% by Lambert (1994), metaframeworks can benefit from the techniques of every model of family therapy, plus multiculturalism, feminism, and psychodynamics.  Adopting those ideas from other models when appropriate will potentially benefit a metaframeworks-oriented therapist without falling prey to any specific model’s blind spots or other weaknesses.  Metaframeworks’ strength is the sum of the strengths of other models.

A pessimist about metaframeworks might argue that the complexity and sophistication of metaframeworks could stand in the way of success.  We still operate inside a 50-minute-per-week schedule, after all, and there’s only so much one can accomplish in that time.  Perhaps metaframeworks is just an extra-confusing and complicated way to provide the benefits of a therapeutic relationship.  If that is the case, metaframeworks may turn out to be somewhat less effective than other models of therapy.

At this point, there is not enough evidence to say who is right, or where on that optimist-to-pessimist spectrum “right” falls.  For the therapist who is a metaframeworks optimist, like myself, it is clearly important to know the model thoroughly, be able to negotiate its concepts and connections fluidly, and to be fluent with nearly all of the interventions of IFS and the other family therapy models.  Not to do so would be to fall prey to the critique of the pessimist.

Critique/Limitations

Though an optimist about metaframeworks, I believe I see weaknesses in the model. As a family therapist in training, all I can offer is a theoretical critique of the theory, and having just made contact with metaframeworks, my critique may be severely limited by my understanding, but it will show the extent of my understanding.

First, it is not clear to me how the IFS model is a true metaframework the way sequences, organization, and the others are, existing at every level of organization.  IFS seems to be primarily a model for working with individuals’ internal dynamics—almost more of a level than a metaframework.  How does a society-level constraint show up in the IFS framework, for example?  Also, once you admit that working with psychodynamics is useful, you will need to justify using a new model like IFS over a more mature model, of which there are many.  The idea of using systems thinking to approach psychodynamics is intriguing but somewhat less intuitive than systems thinking for families.

I have similar questions about the developmental metaframework.  While Breunlin and colleagues (1997) mention changing values at the level of societies, there is no attempt to put forth a developmental scheme.  Change is not development in the psychological sense.  There are society-level developmental schemes available, such as those put forth by Gebser or Graves (e.g. Graves, 1970; Wilber, 2000) which might be useful in creating a true developmental metaframework.  Development is also ignored on the community level, though I have no ideas on how to improve that.  The developmental scheme put forth for individuals, that of oscillation at developmental nodes, is simplistic compared to the wealth of knowledge developmental psychologists have discovered.  They make no mention even of the foundational work of Piaget, Kholberg, or Gilligan.

The gender metaframework has elements of cultural imperialism:  The therapist knows better than the clients and is duty-bound to change them, if possible.  I believe the problem lies in the gender-relations developmental scheme.  In the description of traditional to gender aware to polarized to balanced there is the clear judgment of very bad to less bad to even less bad to good.     While there is truth to this judgment, it limits the therapist, I think.  A better developmental scheme would, as an option, allow for and encourage a positive expression of traditional value-structure,s rather than a simple, negative judgment of the large majority of the earth’s cultures.

Finally, while metaframeworks seems to do an admirable job of integrating the good ideas from the original systems-oriented therapies, it provides no clear space for the good ideas from other therapy models.  I am specifically missing three elements.  First, Johnson’s twin breakthroughs of incorporating attachment theory and a focus on emotions in couples therapy (e.g. Johnson, 2004).  Second, the tools of cognitive therapy for examining meaning and resolving problematic meaning-making (e.g. Beck, 1979).  Third, mindfulness practices and interventions (e.g. Dimeff, Koerner, & Linehan, 2007).

Metaframeworks and Depression in Couples

As a metaframeworks-oriented therapist, when presented with a couple who complain of depression, I would assume that these are naturally resourceful people who are operating under some constraints right now.  It is likely that some number of factors in the web of possible constraints is providing the stresses that have triggered and maintained the symptoms of depression.  I would enter into a conversation with this couple, listening for clues as to what these constraints might be, at what level of organization, and seen clearest with the perspective of which metaframework.

It may be that one of those constraints is biological and at the individual level of organization—that is, a genetic tendency for depression—and that antidepressant medication or some other somatic intervention would be necessary.  If a thorough assessment for suicidality is negative, however, I would try out other hypotheses first, to see if releasing other constraints is adequate, as antidepressant medications have side effects while the releasing of other constraints does not (Breunlin et al., 1997).

I would take the couple’s lead in our conversation.  What do they think is important to talk about?  Chances are, they have some strong and useful ideas about where their stress is coming from, or at least when it is they feel the most stressed and when and where they feel the least stressed.  During the conversation I would keep the metaframeworks in mind, and the levels of organization, listening for clues about which hold the relevant constraints, which I would follow up on, developing and checking out hypotheses.

Do they complain about communication problems?  That would be a clue that the sequences metaframework may be involved at the interaction level.  If that checked out, it might suggest an interaction-oriented intervention, such as Gottman’s soft-startup psychoeducation, or one of Satir’s congruent-communication exercises.  I would also keep in mind the other levels of sequences.  Is there evidence for constraining daily routines?  Any chance of seasonal affective depression or holiday blues?  How about a history of depression in the family, a possible intergenerational sequence?  I would keep in mind that any sequences I come across can interact recursively with each other, generating, maintaining, regulating, or exacerbating each other.  I would hold my hypotheses lightly, listening for evidence against them, and when I felt like I had a good one, I would try an intervention, watching and listening for, and respecting, any feedback I got from the couple.  Whether or not the intervention brought out evidence for or against my hypothesis, I would use that evidence to generate new directions in the conversation, new questions, more accurate hypotheses.

I may come to suspect that internal family systems are involved in the depression, perhaps in the form of a polarization between angry and disappointed parts of each partner, or between perfectionist and overwhelmed parts of one of the partners.  If that seemed like the case, I could try working with the parts, calming the extreme parts and encouraging the leadership of the Self.  Throughout the process, I would keep in mind that both the levels of organization and the metaframeworks interact recursively.  Are these parts reflected in an intergenerational sequence?  A family-level organization pattern? How about a society-level pattern?  I would follow up on any relevant-seeming clues, getting feedback from the couple, developing a richer understanding of their situation.

I would keep an eye out for organizational and developmental constraints.  Does the couple lead their family appropriately?  Are there parentified children? Cross-generational coalitions?  These might begin to suggest structural or strategic interventions, modified for maximum respectfulness, of course.  Are they at a nodal point in the family life cycle? Having their first child? Launching their last child?  Is there evidence of an oscillation in competence?  To what stage has their relationship developed?

I would investigate and keep in mind the couple’s multicultural and gender aspects, watching for friction from a poor cultural fit, or gender-based power dynamics.  Is either partner an immigrant?  Second- or third-generation American?  Is their socioeconomic class a fit with each other, or suffer from the constraints of poverty?  What is their sexual orientation and what other ways do they identify with majority or minority cultures?  How do they think about religion?  Education?  How about gender?  Have they taken on traditional gender roles or have they begun to chafe under them?  Achieved balance?  How might I support the partner who has less power to stand up for themself?  How might I support the partner with more power to more gently move through the transition to gender balance?

Culture and gender are also where I would keep a close eye on myself:  How might my culture and gender be constraining my thinking or compassion with this couple?  How might our similarities or differences blind me to possible constraints?  I would quite possibly check in with a colleague or supervisor about this.

Ideally, I would move our conversation with purpose and fluidity through, and back and forth between, the different metaframeworks and the different levels of organization, identifying and releasing constraints by staging and creating events and reading the feedback.  If the depression was the result of just a few constraints, the process might be fairly simple.  If the depression was the result of a dense, heavily embedded constellation of constraints, the process might take longer and involve many iterations of rethinking, shifting hypotheses, trying out different angles and interventions.  Ideally the process would also be intuitive, so that I could just follow my natural curiosity and the natural flow of our conversation.  And, ideally, as a result of our conversation, the other events, like interventions, we orchestrate in our relationship, and the quality of our relationship, the constraints release and the couple finds that they no longer struggle with depression.

References

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (Revised 4th ed.). Washington, DC: Author.

Anda, R. F., Whitfield, C. L., Felitti, V. J., Chapman, D., Edwards, V. J., Dube, S. R., & Williamson, D. F. (2002). Adverse childhood experiences, alcoholic parents, and later risk of alcoholism and depression. Psychiatric Services, 53(8), 1001–1009.

Andrews, P. W., & Thomson, Jr., J. A. (2009). The bright side of being blue: Depression as an adaptation for analyzing complex problems. Psychological Review, 116(3), 620-654.

Atkins, D. C., Dimidjian, S., Bedics, J. D., Christensen, A. (2009). Couple discord and depression in couples during couple therapy and in depressed individuals during depression treatment. Journal of Consulting and Clinical Psychology, 77(6), 1089-1099. doi:10.1037/a0017119

Atkins, D. C., Marín, R. A., Lo, T. T. Y., Klann, N., & Hahlweg, K. (2010). Outcomes of couples with infidelity in a community​-​based sample of couple therapy. Journal of Family Psychology, 24(2), 212-216. doi:10.1037/a0018789

Ballantine, H. T., Bouckoms, A. J., Thomas, E. K., & Giriunas, I. E. (1987). Treatment of psychiatric illness by stereotactic cingulotomy. Biological Psychiatry, 22(7). 807-819.

Barbato, A. & D’Avanzo, B. (2008). Efficacy of couple therapy as a treatment for depression: A meta-analysis. Psychiatry Quarterly, 79, 121-132.

Baucom, B., Eldridge, K., Jones, J., Sevier, M., Clements, M., Markman, H., Stanley, S., Sayers, S. L., Sher, T., & Christensen, A . (2007). Relative contributions of relationship distress and depression to communication patterns in couples. Journal of Social and Clinical Psychology, 26(6), 689-707. doi:10.1521/jscp.2007.26.6.689

Beach, S. R. & O’Leary, K. D. (1986). The treatment of depressionoccurring in the context of marital discord. Behavior Therapy, 17(1), 43-49. doi:10.1016/S0005-7894(86)80112-5

Beach, S. R. & O’Leary, K. D. (1992). Treating depression in the context of marital discord: Outcome and predictors of response of marital therapy versus cognitive therapy. Behavior Therapy, 23(4), 507-528. doi:10.1016/S0005-7894(05)80219-9

Beardslee, W. R., Wright, E. J., Gladstone, T. R. G.,& Forbes, P. (2007). Long​-​term effects from a randomized trial of two public health preventive interventions for parental depression. Journal of Family Psychology, 21(4), 703-713. doi:10.1037/0893-3200.21.4.703

Beck, A. T. (1976). Cognitive therapy and the emotional disorders. New York: Meridian.

Beck, A. T. (1979). Cognitive therapy and the emotional disorders. New York: Meridian.

Beck, A. T., Steer, R. A., Ball, R., & Ranieri, W. (1996). “Comparison of Beck Depression Inventories -IA and -II in psychiatric outpatients”. Journal of Personality Assessment 67(3): 588–97. doi:10.1207/s15327752jpa6703_13

Bonde, J. P. (2008). Psychosocial factors at work and risk of depression: A systematic review of the epidemiological evidence. Journal of Occupational and Environmental Medicine, 65(7), 438–45. doi:10.1136/oem.2007.038430

Breunlin, D. C. & MacKune-Karrer, B. (2002). Metaframeworks. In F. W. Kaslow (Ed.), Comprehensive handbook of psychotherapy: Integrative/eclectic, Vol. 4, (pp. 367-385). Hoboken, NJ: John Wiley & Sons.

Breunlin, D. C. (1999). Toward a theory of constraints. Journal of Marital and Family Therapy, 25(3), 365-382. doi:10.1111/j.1752-0606.1999.tb00254.x

Breunlin, D. C., Rampage, C., Eovaldi, M. L., & Mikesell, R. H. (1995). Family therapy supervision: Toward an integrative perspective. In D. D. Lusterman & S. H. McDaniel (Eds.), Integrating family therapy: Handbook of family psychology and systems theory, (pp. 547-560). Washington, DC, US: American Psychological Association. doi:10.1037/10172-031

Breunlin, D. C., Schwartz, R. C., & Mac Kune-Karrer, B. (1992). Metaframeworks: Transcending the models of family therapy. San Francisco: Josey-Bass.

Breunlin, D. C., Schwartz, R. C., & Mac Kune-Karrer, B. (1997). Metaframeworks: Transcending the models of family therapy (2^nd ed.). San Francisco: Josey-Bass.

Carter, B. & McGoldrick, M., (1988). The changing family life cycle: A framework for family therapy. (2nd ed.) Boston: Allyn & Bacon.

Caspi, A., Sugden, K., Moffitt, T. E., Taylor, A., Craig, I. W., Harrington, H., McClay, J., Mill, J., Martin, J., Braithwaite, A., & Poulton, R. (2003). Influence of life stress on depression: Moderation by a polymorphism in the 5-HTT Gene. Science, 301, 386-389. doi:10.1126/science.1083968

Chapman D. P., Anda, R. F., Felitti, V. J., Dube, S. R., Edwards, V.J., & Whitfield, C. L. (2004). Epidemiology of adverse childhood experiences and depressive disorders in a large health maintenance organization population. Journal of Affective Disorders 82, 217–225.

Cohen, R. A., Paul, R., Zawacki, T. M., Moser, D. J., Sweet, L., & Wilkinson, H. (2001). Emotion and personality changes following cingulotomy. Emotion, 1(1), 38-50.

Cohen, R. S. & Abed, F. (2003). CD-ROM simulation training in perceptual, conceptual, and executive skills in family therapy: A metaframeworks approach. Journal of Systemic Therapies, 22(3), 27-40. doi:10.1521/jsyt.22.3.27.23356

Cohen, S., O’Leary, K. D., & Foran, H. (2009). A randomized clinical trial of a brief, problem​-​focused couple therapy for depression. Behavior Therapy, 41(4), 433-446. doi:10.1016/j.beth.2009.11.004

Cohen, S., O’Leary, K. D., & Foran, H. (2010). A randomized clinical trial of a brief, problem​-​focused couple therapy for depression. Behavior Therapy, 41(4), 433-446. doi:10.1016/j.beth.2009.11.004

Compas, B. E., Forehand, R., Keller, G., Champion, J. E., Rakow, A., Reeslund, K. L., McKee, L., Fear, J. M., Colletti, C. J. M., Hardcastle, E., Merchant, M. J., Roberts, L., Potts, J. Garai, E., Coffelt, N., Roland, E., Sterba, S. K., & Cole, D. A., (2009). Randomized controlled trial of a family cognitive​-​behavioral preventive intervention for children of depressed parents. Journal of Consulting and Clinical Psychology, 77(6), 1007-1020. doi:10.1037/a0016930

Craighead, W. E., Sheets, E. S., Brosse, A. L., & Ilardi, S. S. (2007). Psychosocial treatments for major depressive disorder. In P. E. Nathan & J. M. Gorman (Eds.), A Guide to Treatments that Work (3^rd ed.) (pp. 289-307). Cary, NC: Oxford.

Cramer, D., Jowett, S. (2010). Perceived empathy, accurate empathy and relationship satisfaction in heterosexual couples. Journal of Social and Personal Relationships, 27(3), 327-349. doi:10.1177/0265407509348384

Cummings, E. M., Keller, P. S., & Davies, P. T. (2005). Towards a family process model of maternal and paternal depressive symptoms: Exploring multiple relations with child and family functioning. Journal of Child Psychology and Psychiatry, 46(5), 479-489. doi:10.1111/j.1469-7610.2004.00368.x

Davila, J., Karney, B. R., Hall, T. W. & Bradbury, T. N. (2003). Depressive symptoms and marital satisfaction: Within-subject associations and the moderating effects of gender and neuroticism. Journal of Family Psychology, 17(4), 557-570. doi:10.1037/0893-3200.17.4.557

Dein, S. (2006). Religion, spirituality and depression: Implications for research and treatment. Primary Care and Community Psychiatry, 11(2), 67–72. doi:10.1185/135525706X121110.

Denton, W. H. Carmody, T. J. Rush, A. J. Thase, M. E. Trivedi, M. H. Arnow, B. A. Klein, D. N. & Keller, M. B. (2010). Dyadic discord at baseline is associated with lack of remission in the acute treatment of chronic depression. Psychological Medicine, 40(3), 415-424. doi:10.1017/S0033291709990535

DeShazer, S. (1988). Clues: Investigating solutions in brief therapy. New York: Norton.

Dessaulles, A., Jonson, S. M., & Denton, W. H. (2003). Emotion focused therapy for couples in treatment of depression: A pilot study. American Journal of Family Therapy 31, 345–353.

Dimeff, L. A., Koerner, K., & Linehan, M. M. (2007). Dialectical behavior therapy in clinical practice: Applications across disorders and settings. New York: Guilford.

Doohan, E. M., Carrère, S. Riggs, M. L. (2010). Using relational stories to predict the trajectory toward marital dissolution: The oral history interview and spousal feelings of flooding, loneliness, and depression. Journal of Family Communication, 10(1), 57-77. doi:10.1080/15267430903396401

Edwards, V. J, Holden, G. W., Anda, R. F., & Felitti, V. J. (2003). Experiencing multiple forms of childhood maltreatment and adult mental health: results from the Adverse Childhood Experiences (ACE) Study. American Journal of Psychiatry, 160(8), 1453–1460.

Ellis, A. (1998). The Albert Ellis reader: A guide to well-being using rational emotive behavior therapy. Secaucus, NJ: Citadel.

Emanuels-Zuurveen, L. & Emmelkamp, P. M. (1996). Individual behavioural-cognitive therapy v. marital therapy for depression in marital distressed couples. British Journal of Psychiatry, 169, 181–188.

Emanuels-Zuurveen, L., Emmelkamp, P. M. (1997). Spouse-aided therapy with depressed patients. Behavior Modification 21, 62–77.

Fisch, R., Weakland, J. H., & Segal, L. (1982). The tactics of change. San Francisco: Josey-Bass.

Fournier, J. C., DeRubeis, R. J., Hollon, S. D., Dimidjian, S., Shelton, R. C., & Fawcett, J. (2010). Antidepressant drug effects and depression severity: A patient-level meta-analysis. Journal of the American Medical Association 303(1), 47-54.

Foy, C. W. & Breunlin, D. C. (2001). Integrative supervision: A metaframeworks perspective. In S. H. McDaniel, D. D. Lusterman, & C. L. Philpot (Eds.), Casebook for integrating family therapy: An ecosystemic approach, (pp. 387-394). Washington, DC: American Psychological Association. doi:10.1037/10395-032

Gabriel, B., Beach, S. R. H., & Bodenmann, G. (2010). Depression, marital satisfaction and communication in couples: Investigating gender differences. Behavior Therapy, 41(3), 306-316. doi:10.1016/j.beth.2009.09.001

Gabriel, B., Bodenmann, G., Widmer, K., Charvoz, L., Schramm, E., & Hautzinger, M. (2008). Effects of cognitive behavior therapy, interpersonal psychotherapy, and coping-oriented couple therapy for the treatment of depression on the observed dyadic coping behavior. Zeitschrift für Klinische Psychologie und Psychotherapie: Forschung und Praxis, 37(3),  179-189. doi:10.1026/1616-3443.37.3.179

Goodman, C. R. & Shippy, R. A. (2002). Is it contagious? Affect similarity among spouses. Aging & Mental Health, 6(3), 266-274. doi:10.1080/13607860220142431

Gottman, J. M., (1999). The marriage clinic: A scientifically-based marital therapy. New York: Norton.

Graves, C. W. (1970). Levels of existence: An open system theory of values. Journal of Humanistic Psychology, 10(2), 131-155. doi:10.1177/002216787001000205

Greenberg, P. E., Kessler, R. C., Birnbaum, H. G., Leong, S. A., Lowe, S. W. Berglund, P. A., & Corey-Lisle, P. K. (2003). The economic burden of depression in the United States : How did it change between 1990 and 2000? Journal of Clinical Psychiatry, 64(12), 1465-1475.

Haley, J. (1984). Ordeal therapy. San Francisco: Josey-Bass.

Hamilton, M. (1980) Rating depressive patients. Journal of Clinical Psychiatry, 41, 21-24.

Holahan, C. J., Moos, R. H., Moerkbak, M. L., Cronkite, R. C., Holahan, C. K., & Kenney, B. A. (2007). Spousal similarity in coping and depressive symptoms over 10 years. Journal of Family Psychology, 21(4), 551-559. doi:10.1037/0893-3200.21.4.551

Jacobson, N. S., Dobson, K., Fruzzetti, A. E. , Schmaling, K. B. (1991). Marital therapy as a treatment for depression. Journal of Consulting and Clinical Psychology 59, 547–557.

Jacobson, N. S., Follette, W. C., & Pagel, M. (1986). Predicting who will benefit from behavioral marital therapy. Journal of Consulting and Clinical Psychology, 54(4), 518-522. doi:10.1037/0022-006X.54.4.518

Johnson, S. M. (2004). The practice of emotionally focused couple therapy: Creating connection. New York: Brunner-Routledge.

Johnson, S. M. (2004). The practice of emotionally-focused couple therapy: Creating connection. New York: Brunner-Routledge.

Kanter, J. W., Cautilli, J. D., Busch, A. M., & Baruch, D. E. (2005). Toward a comprehensive functional analysis of depressive behavior: Five environmental factors and a possible sixth and seventh. The Behavior Analyst Today, 6(1), 65-77.

Keeton, C. P., Perry-Jenkins, M., & Sayer, A. G. (2008). Sense of control predicts depressive and anxious symptoms across the transition to parenthood. Journal of Family Psychology, 22(2), 212-221. doi:10.1037/0893-3200.22.2.212

Kendler, K. S. (2003). Life event dimensions of loss, humiliation, entrapment, and danger in the prediction of onsets of major depression and generalized anxiety. Archives of General Psychiatry, 60(8), 789–796. doi:10.1001/archpsyc.60.8.789.

Kessler, R. C. (1997). The effects of stressful life events on depression. Annual revue of Psychology, 48, 191–214. doi:10.1146/annurev.psych.48.1.191.

Kim, D. (2008). Blues from the neighborhood? Neighborhood characteristics and depression. Epidemiological Revue, 30(1): 101-117. doi:10.1093/epirev/mxn009

Klerman, G. L., Weissman, M. M., Rounsaville, B. J., &Chevron, E. S. (1984). Interpersonal psychotherapy of depression. New York: Basic.

Lambert, M. J. (1992) Psychotherapy outcome research: Implications for integrative and eclectic therapists. In J. C. Norcross & M. R. Goldfried (Eds.), Handbook of psychotherapy integration (pp. 94-129). New York: Basic Books.

Lawson, J. M. (1993). Family therapy: Reading the subtitles. PsycCRITIQUES, 8(4), 409-410. doi:10.1037/033246

Lebow, J. L. (2003). Integrative approaches to couple and family therapy. In T. L. Sexton, G. R. Weeks, & M. S. Robbins, (Eds), Handbook of family therapy: The science and practice of working with families and couples, (pp. 201-225). New York: Brunner-Routledge.

Leff, J., Vearnals, S., Brewin, C. R., Wolff, G., Alexander, B., Asen, E., Dayson, D., Jones, E., Chisholm, E., & Everitt, B. (2000). The London depression intervention trial. Randomised controlled trial of antidepressants v. couple therapy in the treatment and maintenance of people with depression living with the partner: clinical outcome and costs. The British Journal of Psychiatry, 177, 95–100.

Leupnitz, D. (1988). The family interpreted: Feminist theory in clinical practice. New York: Basic.

Luther, C. J. (1995). Utilizing nondirective play therapy interventions within a family therapy model: A theoretical and clinical exploration. Dissertation Abstracts International: Section B: The Sciences and Engineering.

Martins, C. & Gaffan, E. A. (2000). Effects of early maternal depression on patterns of infant–mother attachment: A meta-analytic investigation. Journal of Child Psychology and Psychiatry, 41(6), 737-746. doi:10.1111/1469-7610.00661

McCullough, M., Larson, D. (1999). Religion and depression: A review of the literature. Twin Research, 2(2): 126–136. doi:10.1375/136905299320565997

Mead, D. E. (2002). Marital distress, co-occurring depression and marital therapy: A review. Journal of Marital and Family Therapy, 28(3), 299-314. doi:10.1111/j.1752-0606.2002.tb01188.x

Mehta, N., Cowan, P. A., & Cowan, C. P. (2009). Working models of attachment to parents and partners: Implications for emotional behavior between partners. Journal of Family Psychology, 23(6), 895-899. doi:10.1037/a0016479

Miller, S. D., Duncan, B. L., & Hubble, M. A. (1997). Escape from babel: Toward a unifying language for psychotherapy practice. New York: Norton.

Minuchin, S. & Fishman, H. C. (1982). Family therapy techniques. Boston: Harvard UP.

Monroe, S. M. & Simons, A. D. (1991). Diathesis-stress theories in the context of life stress research: Implications for the depressive disorders. Psychological Bulletin, 110(3), 406-425.

Nehring, K. A. (1998). The metaframeworks approach to treatment of a family in therapy. Dissertation Abstracts International: Section B: The Sciences and Engineering.

Nichols, M. P. & Schwartz, R. C. (2008). Family therapy: Concepts and methods. Boston: Pearson.

Olfson, M., Marcus, S. C., Druss, B., Elinson, L., Tanielian, T., & Pincus, H. A. (2002). National trends in the outpatient treatment of depression. Journal of the American Medical Association, 287(2), 203-210.

Oulvey, E. A. (2000). The relationship of long-term training in a multi-systemic model to changes in epistemic style and the symptoms of burnout. Dissertation Abstracts International: Section B: The Sciences and Engineering.

Papp, L. M. (2010). The course and quality of intimate relationships among psychologically distressed mothers. American Journal of Orthopsychiatry, 80(1), 71-79.

Papp, L. M., Kouros, C. D., & Cummings, E. M. (2010). Emotions in marital conflict interactions: Empathic accuracy, assumed similarity, and the moderating context of depressive symptoms. Journal of Social and Personal Relationships,27(3), 367-387. doi:10.1177/0265407509348810

Patterson, J., Albala, A. A., McCahill, M. E., & Edwards, T. M. (2010). The Therapist’s Guide to Psychopharmacology: Working with Patients, Families, and Physicians to Optimize Care. New York: Guileford.

Perls, F. (1973). The Gestalt approach & eye witness to therapy. Palo Alto, CA: Science & Behavior.

Pinsof, W. M. (1993). Toward a scientific paradigm for family psychology: The integrative process systems perspective. Journal of Family Psychology, 5(3-4), 432-447. doi:10.1037/0893-3200.5.3-4.432

Pinto, A. &Francis G. (1993). Cognitive correlates of depressive symptoms in hospitalized adolescents. Adolescence. 28(111), 661–72.

Rampage, C. (1998). Feminist couple therapy: Case studies in couple and family therapy: Systemic and cognitive perspectives. In F. M. Dattilio (Ed.), Case studies in couple and family therapy: Systemic and cognitive perspectives, (pp. 353-370). New York: Guilford.

Rehman, U. S., Ginting, J., Karimiha, G., Goodnight, J. A. (2010). Revisiting the relationship between depressive symptoms and marital communication using an experimental paradigm: The moderating effect of acute sad mood. Behaviour Research and Therapy, 48(2), 97-105. doi:10.1016/j.brat.2009.09.013

Reich, G. (2003). Depression and couples’ relationship. Psychotherapeut, 48(1), 2-14. doi:10.1007/s00278-002-0280-3

Rogers, C. R. (2003). Client-centered therapy: Its current practice, implications, and theory. London: Carlton.

Sacco, W. P. & Phares, V. (2001). Partner appraisal and marital satisfaction: The role of self-esteem and depression. Journal of Marriage and Family, 63(2), 504-513. doi:10.1111/j.1741-3737.2001.00504.x

Sapolsky, R. (2009, November 10). Depression in the U. S. [Video file]. Retrieved from http://www.youtube.com/user/StanfordUniversity#p/search/2/NOAgplgTxfc. (2010, December 5.)

Satir, V. (1983). Conjoint family therapy. Palo Alto, CA: Science & Behavior.

Sayers, S. L., Kohn, C. S., Fresco, D. M., Bellack, A. S., & Sarwer, D. B. (2001). Marital cognitions and depression in the context of marital discord. Cognitive Therapy and Research, 25(6), 713-732. doi:10.1023/A:1012967222638

Schneider, B. L. (1998). Inpatient treatment of a gang-involved adolescent: A metaframeworks analysis. Dissertation Abstracts International: Section B: The Sciences and Engineering.

Schwartz, R. C. & Grace, P. (1989). The systemic treatment of bulimia. Journal of Psychotherapy & the Family, 6(3-4), 89-105. doi:10.1300/j085V06N01_09

Schwartz, R. C. (1987). Working with “internal and external” families in the treatment of bulimia. Family Relations, 36(3), 242-245. doi:10.2307/583534

Segrin, C. (2004). Concordance on negative emotion in close relationships: Transmission of emotion or assortative mating? Journal of Social and Clinical Psychology, 23(6), 836-856. doi:10.1521/jscp.23.6.836.54802

Sher, T. G., Baucom, D. H., & Larus, J. M. (1990). Communication patterns and response to treatment among depressed and nondepressed maritally distressed couples. Journal of Family Psychology, 4(1), 63-79.

Slavich, G. M., Thornton, T., Torres, L. D., Monroe, S. M., & Gotlib, I. H. (2009). Targeted rejection predicts hastened onset of major depression. Journal of Social and Clinical Psychology, 28, 223–243. doi:10.1521/jscp.2009.28.2.223.

Strauss, W. & Howe, N. (1991). Generations: The history of America’s future, 1584 to 2069. New York: Quill.

Teichman, Y., Bar-El, Z., Shor, H., Sirota, P., & Elizur, A. (1995). A comparison of two modalities of cognitive therapy (individual and marital) in treating depression. Psychiatry 58, 136–148.

Tilden, T., Gude, T., Hoffart, A., Sexton, H. (2010). Individual distress and dyadic adjustment over a three​-​year follow​-​up period in couple therapy: A bi​-​directional relationship? Journal of Family Therapy, 32(2), May 2010, 119-141. doi:10.1111/j.1467-6427.2010.00490.x

Tilden, T., Gude, T., Sexton, H., Finset, A., & Hoffart, A. (2010). The associations between intensive residential couple therapy and change in a three​-​year follow​-​up period. Contemporary Family Therapy: An International Journal, 32(1), 69-85. doi:10.1007/s10591-009-9104-8

Timko, C., Cronkite, R. C., Swindle, R., Robinson, R. L., Turrubiartes, P. & Moos, R. H. (2008). Functioning status of adult children of depressed parents: A 23​-​year follow​-​up. Psychological Medicine, 38(3), 343-352. doi:10.1017/S0033291707002073

Unutzer, J., Katon, W., Callahan, C. M., Williams, J. W., Hundeler, E., Harpole, L., Hoffing, M., Della Penna, R. D., Hitchcock Noel, P., Lin, E. H. B., Tang, L., & Oishi, S. (2003). Depression treatment in a sample of 1,801 depressed older adults in primary care. Journal of the American Geriatric Society, 51, 505-514.

Vaeth, P. A. C., Ramisetty-Mikler, S., Caetano, R. (2010). Depression among couples in the United States in the context of intimate partner violence. Journal of Interpersonal Violence, 25(5), 771-790. doi:10.1177/0886260509336957

Vilhjalmsson, R. (1993). Life stress, social support and clinical depression: A reanalysis of the literature. Social Science & Medicine, 37(3), 331–42. doi:10.1016/0277-9536(93)90264-5.

Wampold, B. E. (2001). The great psychotherapy debate: Models, methods, and findings. Mahwah, NJ: Erlbaum.

Whisman, M. A., Schonbrun, Y. C. (2010). Marital distress and relapse prevention for depression. In R. C. Steven & M. G. Perri (Eds.), Relapse prevention for depression (pp. 251-269). Washington, DC: American Psychological Association. doi:10.1037/12082-010

Whisman, M. A., Weinstock, L. M., & Uebelacker, L. A. (2002). Mood reactivity to marital conflict: The influence of marital dissatisfaction and depression. Behavior Therapy, 33(2), 299-314. doi:10.1016/S0005-7894(02)80030-2

White, M. & Epston, D. (1990). Narrative means to therapeutic ends. New York: Norton.

Whitton, S. W., Olmos-Gallo, P. A., Stanley, S. M., Prado, L. M., Kline, G. H., St. Peters, M., & Markman, H. J. (2007). Depressive symptoms in early marriage: Predictions from relationship confidence and negative marital interaction. Journal of Family Psychology, 21(2), 297-306. doi:10.1037/0893-3200.21.2.297

Wilber, K. (2000). Integral psychology: Consciousness, spirit, psychology, therapy. Boston: Shambala.

Wilkins, E. J. (2007). Using an IFS informed intervention to treat African American families surviving sexual abuse: One family’s story. Journal of Feminist Family Therapy, 19(3), 37-53. doi:10.1300/J086v19n03_03

Wu, J. C. & Bunney, W. E. (1990). The biological basis of an antidepressant response to sleep deprivation and relapse: Review and hypothesis. American Journal of Psychiatry, 147(1), 14-21.

Wynne, L. C. (1988). An epigenetic model of family processes. In C. J. Falicov (Ed.), Family transitions: Continuity and change over the life cycle. New York: Guilford.

Yalom, I. (2009). The gift of therapy: An open letter to a new generation of therapists and their patients. New York: Harper Perennial.

Appendix

	Mind	Sequence	Organization	Development	Culture	Gender
Society
Community
Family
Relationship
Person
Biology

Figure 1. The levels of organization as conceptualized by Breunlin, Schwartz, and Mac Kune-Karrer (1997) are on the vertical axis and the metaframeworks are on the horizontal axis.