Policy briefings

Relationship Advice

Children's mental health and inter-parental conflict

Research conclusively demonstrates that exposure to frequent, intense and poorly resolved inter-parental conflict puts children’s mental health at risk (Harold et al, 2016).

“Family relationships” is the second most common reason why children contact ChildLine (NSPCC, 2018).

It is also the most commonly cited presenting problem inyoung people’s IAPT services: in a sample of over 42,000 children being seen across 75 young people’s IAPT services, family relationships was cited by professionals in 52% of cases (Wolpert, 2017).

Furthermore, interviews with nine clinicians working in an inner London CAMH service, covering 313 cases, revealed that inter-parental conflict had contributed significantly to the mental health difficulties of the child or young person for nearly half of all cases (Mees, 2017).

Why does couple therapy not form part of the standard CAMHS offer?

The list of practitioners which comprise atypical CAMH service includes: psychiatrists, psychologists, social workers, nurses, and psychological therapists – this may include child psychotherapists, family psychotherapists, playtherapists and creative art therapists.

The reasons for the omission of couple therapists from this list largely relate to the fact that couple therapy, as a profession, has historically sat outside of the NHS. This is largely because, after the second world war, “the Government of the day was not convinced that the state had any business directly intervening in the private lives of familiesand so gave funding to set up National Marriage Guidance services to offer advice and assistance”(Hewison, 2017).

While the evidence base for couple therapy – in terms of its effectiveness in improving relationshipquality and reducing relationship distress – is strong (e.g. Shadish and Baldwin, 2013; Hewison,2016), the fact that there has been very little research conducted on the impact of couple therapy in improving the mental health of children whose parents receive it, has also had the effect of maintaining the position of couple therapy outside of CAMHS.

This is a regrettable position. But while the impact of inter-parental conflict and relationship breakdownhas long been recognised (for example as long ago as 1947 The Report of the Matrimonial Causes Procedure Committee could acknowledge “the effect of broken marriages upon children”), there is now much more interest in exploring ways of working to alleviate the impact on children. Indeed, in 2017, the Manifesto for Strengthening Families (backed by more than 50 MPs) argued that “couple counselling should be available for parents within Children and Young People’s Mental Health teams as a matter of course” (Bruce, 2017).

The Early Intervention Foundation’s review (Haroldet al., 2016), which showed not only the impact of inter-parental conflict on children’s mental health, also highlighted the degree to which the mental health needs of children affected by interparental conflict are currently unmet. Moreover, it made a particular point of stressing that parenting interventions – which do not include a focus on addressing inter-parental conflict – are not sufficient: “just targeting the parental–child relationship in the context of ongoing interparental conflict does not lead to sustained positive outcomes for children”.

This is a crucial point, since CAMH services often provide parenting support only. In fact, responses to a freedom of information request submitted by Lord Farmer’s office in 2017 revealed that only a tiny fraction of services work directly to address conflict and relationship distress between children referred to CAMH services.

Developing practice

While it is probably fair to say that the practice of couple work in CAMH services is not widespread,there are nevertheless pockets of interesting and innovative practice. Two such are presented below.

Case study 1:

The Tavistock and Portman NHS Foundation Trust’s CAMH service estimates that 40% of parents of the children referred to the service have extremely poor relationships, whether they are living together or separated. The acknowledgement that, where there is inter-parental conflict, whatever work is done with the child will be undone if the couple relationship isn’t improved, led to discussions in 2017 between the Trust and the charity Tavistock Relationships about the creation of an honorary couple therapist role in the service.

The service already runs yearly Parents as Partners Therapy Groups. This intervention is unusual, especially in the UK, in that addresses family-wide issues by targeting the couple relationship, and is unique in its integration of issues in the couple relationship, parenting and the psychological wellbeing of parents and children.

Parents’ responses to the follow-up questionnaires administered about one month after the groups ended showed positive changes in their psychological wellbeing (global psychological distress and parenting stress), multiple measures of couple relationship quality (satisfaction, overall conflict, conflict about children, violent problem solving), father involvement (for those initially less involved), and their children’s problematic behaviours.

Over the following two years, a couple therapist (trained and employed by Tavistock Relationships) treated more than 10 couples, delivering around 300 sessions of couple therapy to parents of children referred to CAMHS. For some of these cases, the dysfunctional parental relationship was the primary cause of the child/ren’s presenting symptoms. For others, the child had difficulties of their own, e.g. ADHD, depression, anxiety but the parental difficulties were either getting in the way of their treatment or exacerbating the symptoms. In some cases the child’s chronic illness had caused the parental conflict, which was then keeping the child stuck in a negative cycle and impeding recovery.

Both the psychiatrist leading the multidisciplinary team and also the social worker in the service found that having a couple therapist with a psychoanalytic training and perspective was invaluable in helping parents reflect on the nature and quality of their relationships, as well as enabling the service as a whole to think about couple dynamics from a psychoanalytic perspectiveenabling the service as a whole to think about couple dynamics from a psychoanalytic perspectivemore often and in a more thorough way. Such was the demand for her time from the outset that the couple therapist was quickly seeing six or seven couples per week, with a waiting list. In some cases, particularly where the dysfunction between the couple was marked, only the parents were seen. In others, work with the parents would run alongside treatment of the child.

The couple therapist was an active contributor to the multidisciplinary CAMHS team, working with social workers psychologists and child psychotherapists who acknowledged thatimproving the family environment was key to improving children’s mental health outcomes.The couple therapist was clear that what she was able to bring to the team was a new way of lookingat the couple as a patient; for while many of the members of the multi-disciplinary team had beentrained to work with parents, their focus was on family dynamics and the relationships between parents and children, rather than the couple relationship and couple conflict specifically. Had the couple therapist not been in post, some parents experiencing significant levels of inter-parental conflict affecting their children would not have been given any help that specifically targeted this issue.

While family therapists, psychologists and child psychotherapists in the team do work with parents separatelyto their children, they rarely have a mandate to address intra-couple dynamics directly. Using a stepped care model, Jenny saw all the referred couples for a 3-4 session assessment intervention, in which their difficulties / conflicts were identified and worked with. Several couples were able in this period to understand the impact their conflict was having on their children’s mental health, and the causal link to their poor behaviour, in a way that hadn’t been possible before. For most this was followed by a period of 4-6 months treatment weekly. For others it felt more appropriate to refer them for couple therapy elsewhere – in the Couples Unit at the Tavistock Clinic, or at Tavistock Relationships. A smaller number were seen for a year or more in treatment, when their difficulties were severe, and more input was needed to stabilise their relationship.For some couples the outcome of the work was that they were helped to separate in a way that reduced the negative impact on the children, and strengthened the ability of the couple to co-parent successfully.

Promisingly, outcomes for children (as well as parents) were very good, with reductions in children’s mental health problems and behavioural issues, and many of the cases closed as a result of thisintervention.

Case study 2:

Hackney Council employs a couple therapist within the clinical service embedded in its Children’s Services. This service is part of the CAMHS alliance, and therefore is linked to Hackney’s NHS CAMH service.

The couple therapist, who had applied for the role of Specialist Clinical Practitioner, was employed on account of the particular skills that she could bring to the multidisciplinary team. This service had not only a longstanding tradition of family therapy but has also included a couple therapy service in the past.Hackney Council employs a couple therapist within the clinical service embedded in its Children’s Services. This service is part of the CAMHS alliance, and therefore is linked to Hackney’s NHS CAMH service. The couple therapist, who had applied for the role of Specialist Clinical Practitioner, was employed on account of the particular skills that she could bring to the multidisciplinary team. This service had not only a longstanding tradition of family therapy but has also included a couple therapy service in the past.

The impact of couple relationships is frequently discussed within the service. Indeed, couple therapy is something that is often explored with parents, as an option that might be offered to them. The fact that it can be offered to them allows them to then start to think about their relationship. And even if they don’t all up end in the clinic, the fact that it is there is meaningful.The family therapists and the couple therapist in the service work in different ways. What is unique about couple therapy is the focus upon the couple relationship itself, destructive conflict, repeated negative dynamics etc. What this brings to the CAMHS team is a worker who is trained to understand and has the skills to work directly with high conflict couples.

The couple therapist in this service has found the rest of her team to be interested in her role and what she can bring. While sometimes providing couple therapy directly to couples – mostly working on a six session model in a Couple Therapy Clinic, or for longer in other cases – she will often work in a consultative capacity, with the social workers from across the service often seeking out her advice regarding the couples they are working with.

In many instances, where a couple is unwilling to attend therapy sessions, the couple therapist can advise the social worker on how to address the issue of conflict with parents and suggest ways of approaching it. Social workers have reported that this can be extremely helpful for them as practitioners and the work they can then do with a couple may lead on to them being more willing to engage with therapeutic work at a later date.Were her role not to exist, the couple therapist believes that many children would continue to act out, at home and in school, the parental conflict they experience (whether overt or silent).

Couple work with the parents provides a unique intervention, which couples – many of whom have never had any therapy before – can benefit from, and often find very containing. For rather than being defensive about receiving help, parents often welcome the fact that there are lots of minds on their relationship. Generally, parental wellbeing improves, the couple therapist believes, as a result of couple therapy provision.

Next steps

We believe that many CAMH service managers, andtheir multi-disciplinary teams, would welcome theaddition of a couple therapists into their services.Indeed, given the survey referred to earlier, in whichclinicians judged that 57% of those children affectedby inter-parental conflict would see their mental health difficulties continue if the conflict were not resolved/improved, it is hard to argue against their inclusion inthe service (Mees, 2017).

Such a view is informed by qualitative research, which Tavistock Relationships has conducted with CAMHS clinicians, CAMHS commissioners and policy-makersin the field. A former Director of the children’s mental health charity YoungMinds, who was interviewed as part of this work, said: “If I were to open a clinic, I’d have acouple therapist in addition to a family therapist. I think the parental couple element in child development, in child psychopathology, is highly significant”; while a CAMHS clinician noted that “most of the time, when clinicians understand that the relationship betweenthe parents is directly affecting the mental health of a child, nothing gets done about it”.

Furthermore, another CAMHS clinician observed that “I would suggest about 90% of the cases I see would require a couple intervention - there’s very few of the kids we see that don’t have some parental aspects that need also to be addressed” (Tavistock Relationships, 2016).

We are therefore calling on the Government to fund pilot projects of couple work in CAMHS in order further explore and develop the potential for this kind ofintervention to alleviate children’s mental health problems.

References

Bruce, F. (2017) Manifesto to Strengthen Families.Bruce, F. (2017) Manifesto to Strengthen Families.

Casey, P., Cowan, P. A., Cowan, C. P., Draper, L., Mwamba, N. and Hewison, D. (2017) Parents as Partners: A U.K. Trial of a U.S. Couples-Based Parenting Intervention For At-Risk Low-IncomeFamilies, Family Process.

Cowan, C. P., Cowan, P. A. and Barry, J. (2011) Couples’ Groups for parents of pre-schoolers:ten-year outcomes of a randomized trial, Journal of Family Psychology, 25, 2, pp. 240

Cowan, P. and Cowan, C. P. (2002) Interventions as tests of family systems theories: Maritaland family relationships in children’s development and psychopathology, Development and Psychopathology, 14, pp. 731-759 l.

Harold G, Acquah D, Sellers R, and Chowdry H (2016) What works to enhance inter-parental relationships and improve outcomes for children? DWP ad hoc research report no. 32. London:DWP.

Hewison, D. (2017) In Encyclopedia of Couple and Family Therapy, edited by Lebow, J.,Chambers, A., Breunlin, D. C. Springer International Publishing Fees, P. (2017) One and One and One is Minus Three: Therapeutic Consultations in Child andAdolescent Mental Health Services with Separated and Conflicted Parents. Journal of Infant, Child and Adolescent Psychotherapy, 16, 3.

NSPCC (2018), The courage to talk: Childline annual review 2017/18. London: NSPCC

Tavistock Relationships (2016) Working with the parental couple in CAMHS – themes emerging from interviews with CAMHS clinicians and commissioners. https://tavistockrelationships.ac.uk/policy-research/reports/1249-working-with-the-parental-couple-in-camhs-themes-emerging-from-interviews-with-camhs-clinicians-and-camhs-commissioners-in-2016

Wolpert, M. (2017) Outcomes for children and young people seen in specialist mental healthservices.

The role of children’s centres in supporting parental relationships: a policy briefing from the Relationships Alliance. (Click here to download the PDF file)

Background

In July 2013, the Government consulted on its proposals to introduce “a new core purpose for children’s centres” which would entail “a stronger focus on school readiness and supporting families”. This new core purpose was to include:

Child development and school readiness - supporting communication, emotional, physical and social development so children start school confident and able to learn.
Parenting aspirations and parenting skills - helping parents to maximise their skills and give their children the best start.
Child and family health and life chances - promoting good physical and mental health for children and their parents, including addressing risk factors early on.

In December 2013 the Education Committee stated in a report that it considered the proposed core new purpose to be “too vague and broadly worded and should be reviewed to focus on achievable outcomes for children and families and to recognise the difference between centres. This should include reaching clarity on who centres are for—children or parents—and what their priority should be” (Education Committee, 2013).

It is clear therefore that there has been, and remains, some disagreement and disquiet in policy circles about what children’s centres should focus on (indeed the Education Committee were sufficiently unhappy with the Government’s response to its report that it recalled the Minister to provide fresh evidence).

It is against this backdrop that the Relationships Alliance is publishing this briefing on an aspect of children’s centre work which neither the Government nor the Education Committee has paid sufficient attention to, that of the importance of couple relationships to children’s outcomes and the role of children’s centres in supporting this.

Why should supporting parental couple relationships be a core part of what children’s centres do?

In recent years, a number of organisations have argued that parenting approaches need to pay more attention to the quality of the relationship between parents and not just on the individual mother/child or father/child relationship.

For example, the Tavistock Centre for Couple Relationships has argued that “it is the nature and quality of the relating that takes place between the parental couple which has the most profound effect on the outcomes, behaviour and development of children. Failure either to recognise this, or to tailor programmes to meaningfully address it, means that a great deal of well-intentioned activity is undertaken with parents which is far less beneficial to those parents than they might suspect” (TCCR, 2011); while the Wave Trust has put forward the view that: “It is important to look beyond those studies that focus only on the relationship between mothers and their young children, because these do not cover the whole picture. For example, the strength of the relationship between parents, as well as relationships between children and their parents, can have a significant impact on young children’s development. Studies also identify a number of protective factors that can minimise the effects of children’s adjustment to family breakdown. These include competent and warm parenting, parents’ good mental health, low parental conflict, cooperative parenting post separation and social support” (Wave Trust, 2013).

In addition, a number of organisations have called for the children centre model to be modified so that it can incorporate a wider, family and relationships-focused remit. For example, the Centre for Social Justice has suggested that children’s centres should incorporate into their remit “providing preventive relationship support at key points in a couple’s relationship and supporting families in difficulty by working with them, where possible and appropriate, to resolve conflict and find solutions to challenges” (Centre for Social Justice, 2011); while the Innovation Unit has suggested that: “Children’s centres could be renamed as Centres for Children and Families. Such a change would indicate an increased focus on supporting families to support their children. Staff in the new Centres for Children and Families will need to deepen their engagement with families” (Innovation Unit, 2010).

That children’s centres should become entities which might be better described as Family Centres, Family Relationship Centres or Family Hubs is something which the Relationships Alliance supports; indeed, we are encouraged that children’s centres in Plymouth, Staffordshire, Derbyshire and Lincolnshire are already starting to move toward this concept.

Core members of the Relationships Alliance have experience, in different ways, of making this more of a reality than simply an aspiration, and brief descriptions of these organisations’ experience are provided as case studies below. In addition, an outline of the Australian model is included.

Relationship support as a core function of children’s centres – some case studies

Relate - Derby and Southern Derbyshire

Relate has been working in children’s centres for a number of years, delivering a range of services including relationship counselling, IAPT couple counselling for depression, psychosexual therapy, family counselling, and children and young people’s counselling. The families seen by Relate staff working in these centres include those with the most complex of needs, such as those who have a large number of children and who are struggling to cope with significant long term and complex issues – including domestic abuse, substance misuse, depression and chaotic life styles.

Families benefits from the offer of services from children centres in numerous ways, including:

The majority of clients who attend counselling at a children’s centre would have been highly unlikely to self-refer into Relate’s general services at its own centres, often because of lack of funds or a reluctance to travel outside of their local community or to an unfamiliar location.

The Tavistock Centre for Couple Relationships - training frontline staff

TCCR offers a foundation level and an advanced level courses for children centre and early year’s leadership staff. These courses are underpinned by a substantial body of evidence demonstrating the importance of the couple relationship on adult and child mental health on children’s lifetime outcomes, and on the physical and mental health of patients and their families (Cowan and Cowan, 2002; Harold and Leve, 2012); along with evidence of the increasing risk of anxiety and depression, aggression, hostility and anti-social behaviour from sustained inter-parental conflict (Cummings and Davies, 2002; Harold et al., 2004).

These courses look at:

Identifying couple distress within family problems
Teaching the evidence base around family conflict and impacts on children
Understanding referral pathways
Father inclusiveness
Skills training including mentalization approaches
Tools and measures to demonstrate value and effectiveness
Maintaining a couple state of mind: holding both partners’ points of view and developing an even handed approach
How to think about partner dissatisfaction and conflict in attachment terms
The importance of supervision, supervisory triangles (client-worker-supervisor relationships) and how to manage organisational dynamics, demands and requirements.

OnePlusOne

The aims of OnePlusOne’s ‘Relationship support: an Early Intervention’ training programme are to enable frontline practitioners to:

Recognise relationship difficulties,
Respond using active listening skills and solution focused techniques in a time managed way, and
Review the need for further support.

Based on the charity’s Brief Encounters® model, this training programme encourages frontline professionals to consider the client’s relationship whilst still operating on their initial agenda (whether this is education, health or housing for example). Becoming relationally minded may often help with the presenting problems (such as health, for example) as relationship issues may underlie these.

Research on the Brief Encounters® with health visitors (Simons et al., 2001) has shown a three-fold rise in mothers identified as needing relationship support (21% of the 459 mothers in the intervention sites compared to 5% of the 502 from the control sites), a five-fold increase in the percentage actually offered help (18% versus 3% respectively) and a doubling of the numbers of mothers discussing relationship problems with their health visitor.

A separate randomised control trial of ‘Relationship Support: An Early Intervention’ with children’s centre staff (Coleman et al., 2014) showed this blended (online and face-to-face) training to have had a large and positive impact on how staff responded and how they had handled conversations with parents about their relationship difficulties. Children centre workers who had received the training were more than twice as likely as those in the control group to be confident in knowing both where and how to refer parents on for further support. The training also increased the likelihood of offering equivalent support in the future.

Family Relationship Centres - Australia

Australia would appear to offer the UK an interesting model. Its network of 65 centrally-funded family relationship centres provides a source of information and confidential assistance for families at all stages in their lives. The centres have a focus on relationship support, including providing family dispute resolution (mediation) to enable separating families achieve workable parenting arrangements outside the Court system.

These centres aim to assist:

couples about to be married to get information and referral to pre-marriage education
families wanting to improve their relationships to get information and referral to other services that can help strengthen relationships
families having relationship difficulties to get information and referral to other services that can assist them to work through their issues
separated parents to resolve disputes and reach agreement on parenting arrangements outside the court system where appropriate, through child-focused information, advice and family dispute resolution, as well as referral to other services
separated parents whose arrangements have broken down or whose court orders have been breached, to resolve the issue outside the court system where possible and appropriate, through information, advice, referral and family dispute resolution
grandparents and other extended family members affected by a family separation through information, advice, referral or family dispute resolution services, and families to achieve effective resolution of more complex family separation issues through closer linkages with the courts, legal assistance providers and other services within the family law system (DSS, 2011).
as the Department responsible for both children’s centres and relationship support, the Department for Education should play the lead role in making the provision of support for parental and co-parenting relationships a core function of children’s centre work;
the Department for Education should, given the research demonstrating the impact of parental and co-parenting relationship quality on children’s outcomes, also explore the case for children’s centres being developed into Family Relationships Centres (or similar);
the training of the early years workforce (including health visitors, children’s centre managers and workers) should include a mandatory component covering the impact of the couple relationship on child mental health and on children’s lifetime outcomes as well as techniques which the early years workforce can use to ‘think couple’ and help support the couple and co-parenting relationships of parents they work with; the current state of affairs – whereby frontline workers in children’s centres effectively only work with 50% of the parenting resource which a child has – is unacceptable, and the relevant bodies responsible for curriculum planning for these professions should address this as a matter of urgency;
the Early Intervention Foundation, the Education Endowment Foundation and the National Institute for Health and Clinical Excellence should recognise in their publications and guidance the impact which the quality of parental or co-parenting relationships has on children’s outcomes; such a recognition would be of great significance in helping to cement the importance of the parental couple relationship in early years approaches;
Commissioners of Early Years services and Children’s Centres should include, specifically within contracts, a requirement that work within such settings includes the capacity to work effectively with the parental or co-parenting couple and that such work is measured as to its effectiveness with a standardised, reliable measure such as the Parenting Alliance Measure or equivalent.

Policy recommendations

It was encouraging that the All Party Parliamentary Groups for Sure Start Children’s Centres, Strengthening Couple Relationships, and Conception to Age 2: The First 1001 Days held a joint meeting recently at which there was a great deal of support for the concept of embedding relationship support within the work of children’s centres.

To make this a reality however, the Relationships Alliance believes that:

as the Department responsible for both children’s centres and relationship support, the Department for Education should play the lead role in making the provision of support for parental and co-parenting relationships a core function of children’s centre work;
the training of the early years' workforce (including health visitors, children’s centre managers and workers) should include a mandatory component covering the impact of the couple relationship on child mental health and on children’s lifetime outcomes as well as techniques which the early years workforce can use to ‘think couple’ and help support the couple and co-parenting relationships of parents they work with; the current state of affairs – whereby frontline workers in children’s centres effectively only work with 50% of the parenting resource which a child has – is unacceptable, and the relevant bodies responsible for curriculum planning for these professions should address this as a matter of urgency;
the Early Intervention Foundation, the Education Endowment Foundation and the National Institute for Health and Clinical Excellence should recognise in their publications and guidance the impact which the quality of parental or co-parenting relationships has on children’s outcomes; such a recognition would be of great significance in helping to cement the importance of the parental couple relationship in early years approaches;
Commissioners of Early Years services and Children’s Centres should include, specifically within contracts, a requirement that work within such settings includes the capacity to work effectively with the parental or co-parenting couple and that such work is measured as to its effectiveness with a standardised, reliable measure such as the Parenting Alliance Measure or equivalent.
the Department for Education should, given the research demonstrating the impact of parental and co-parenting relationship quality on children’s outcomes, also explore the case for children’s centres being developed into Family Relationships Centres (or similar);

References

Centre for Social Justice (2011). Strengthening the Family and Tackling Family Breakdown - Fatherlessness, dysfunction and parental separation/divorce. A policy paper by the Centre for Social Justice. http://www.centreforsocialjustice.org.uk/UserStorage/pdf/Pdf%20reports/StrengtheningtheFamily.pdf

Coleman, L., Houlston, C., Casey, P., Purdon, S., Bryston, C., 2014. A Randomised Control Trial of a Relationship Support Training Programme for Frontline Practitioners Working with Families. Fam. Relatsh. Soc. forthcoming.

Cowan, P.A., Cowan, C.P., 2002. Interventions as tests of family systems theories: Marital and family relationships in children’s development and psychopathology. Dev. Psychopathol. 14, 731–759.

Cummings, E.M., Davies, P.T., 2002. Effects of marital conflict on children: recent advances and emerging themes in process-oriented research. J. Child Psychol. Psychiatry 43, 31–63.

DSS (2011) Operational Framework for Family Relationship Centres. Revised August 2011. Department of Social Services - Australian Government http://www.dss.gov.au/sites/default/files/documents/frcs_operational_framework.pdf

Education Committee (2013). Foundation Years: Sure Start children’s Centres: Fifth Report of Session 2013-14. Volume 1. http://www.publications.parliament.uk/pa/cm201314/cmselect/cmeduc/364/364.pdf

Harold, G.T., Shelton, K.H., Goeke-Morey, M.C., Cummings, E.M., 2004. Marital conflict, child emotional security about family relationships and child adjustment. Soc. Dev. 13, 350–376.

Harold, G., Leve, L., 2012. Parents and Partners: How the Parental Relationship affects Children’s Psychological Development, in: Balfour, A., Morgan, M., Vincent, C. (Eds.), How Couple Relationships Shape Our World: Clinical Practice, Research and Policy Perspectives. Karnac, London.

Innovation Unit (2010). 21st century children’s centres. http://www.innovationunit.org/sites/default/files/21st%20century%20children's%20centres.pdf

Simons, J., Reynolds, J., & Morison, L. (2001). Randomised controlled trial of training health visitors to identify and help couples with

relationship problems following a birth. British Journal of General Practice, 51, 793-799.

TCCR (2011). Parenting work which focuses on the parental couple relationships: a policy briefing paper from TCCR. http://www.tccr.ac.uk/policy/policy-briefings/276-parenting-work-tccr-policy-briefing

Wave Trust (2013). Conception to age 2 – the age of opportunity. Addendum to the Government’s vision for the Foundation Years: ‘Supporting Families in the Foundation Years’.

The Relationships Alliance, a corsortium comprising Relate, Marriage Care, One Plus One and the Tavistock Centre for Couple Relationships, exists to ensure that good quality personal and social relationships are more widely acknowledged as central to our health and wellbeing.

Couple relationships and work; work and couple relationships: a policy briefing from the Relationships Alliance. (Click here to download the PDF file)

Introduction

This briefing looks at what research tells us about the impact of our working lives on our family lives (including our couple relationships) as well as the impact of our family lives (including our couple relationships) on our working lives.

Such impact, research indicates, can be both negative as well as positive: conflict which stems from work and which spills over into the family as well as conflict which stems from the home and which spills over into work have both been shown to have consequences which include lower job satisfaction, dissatisfaction with the couple relationship, greater likelihood of wanting to find new employment, greater psychological strain, increased somatic/physical symptoms, higher levels of depression, and greater likelihood of burnout (Allen, 2000) (Byron, 2005) (Ford, 2007) (McNall, 2010). While the quality of our couple relationships has also been shown to be associated with the degree to which we are engaged in, and fulfilled by, our work (Burnett, 2012); with some employment practices (for example the option to work flexibly coupled with having a supportive supervisor/line-manager) being linked to improved home life.

The Relationships Alliance believes that a solid argument exists for the research conclusions from the studies highlighted in this briefing being translated by business and Government into action to support relationships; the briefing therefore concludes with a short section presenting what we see as the policy implications of research in this field.

Work and couple relationships

Work-related factors which have a negative impact on couple relationships

Long hours

Working long hours – research suggests that over half of employees (rising to 67% of men) work more than 40 hours a week (Swan, 2005a) (Kersley, 2004) (Isles, 2005) – is associated with a range of problems. Not all couples where one or more partner works long hours report these difficulties; nevertheless many do, and they include:

increased strain on relationships (CIPD, 1998)
relationship break-up (CIPD, 1998)
arguing with their partner (CIPD, 2011)
guilt about not performing their share of domestic duties (CIPD, 2011)
negative impact on sex life(CIPD, 2011)
loss of, or reduced, libido in the last twelve months due to work-related tiredness (CIPD, 2011).
negative impact on relationship with children of school age or younger (CIPD, 2001) (La Valle, et al., 2002)
negative impact on relationship with adolescent children (Crouter, 2001)
children’s unhappiness with parent working longer hours (CIPD, 2011)
reduced contact with children i.e. not seeing children before they go to bed; having too little time to help the children with their homework; missing a child's birthday or school event (CIPD, 1998).
dissatisfaction with work/life balance (CIPD, 2011)
increased family conflict (Bakker, 2009) especially for those with pre-school children (Hill, 2001)
increased depression, stress-related health problems, marital problems, poor job performance, absenteeism, or high staff turnover (Major, 2002).

Research suggests that the relationship between marital or relationship dissatisfaction and longer hours may depend on a number of factors however. These include:

whether a couple has children and how satisfied the person working long hours is with their job (van Steenbergen, 2011)
the gender of the partner (research on the employment of married women finds that marital quality is negatively affected by the reduced time spent together as a result of working longer hours (Hill 1998, Kingston and Nock 1987; Spitze and South 1985), and that married women working longer hours experience increased feelings of role conflict (Voydanoff 1988) and are more aware of the unequal division of household chores (Booth et al. 1984, Spitze and South 1985). One study however suggests that increases in wives' workload corresponds with increased marital satisfaction (van Steenbergen, 2011)).
the structure of work, or how work hours fit in with family life (Barnett, 2008) (Gareis, 2002) (Davis, 2008) (Perry-Jenkins, 2007) (Barnett, 2006).

Porous work-/home-life boundaries as a result of mobile technology

The impact of using mobile technology (e.g. the use of a Blackberry or similar device for accessing email outside of work hours) on work-life balance and relationships is an increasing area of study, with studies showing that:

for the family and friends of those who use mobile technology (for work) during non-working hours, “work is now visibly occupying time in the non-work domains that were previously off-limits.” (Middleton, 2008)
the negative spillover from work-related mobile phone use is linked to higher levels of distress and lower levels of family satisfaction (Chesley, 2005)
flexible working may allow job demands to penetrate further into the home domain, particularly through technological change that means individuals can work almost anywhere (Schieman, 2009).

However, one study, based on data from 281 office workers, has found that maintaining impermeable work and home domains by creating more boundaries around the use of mobile technology for work-related purposes can be beneficial for employees' psychological health (Park, 2011); however another study indicates that while communication via BlackBerry can result in fewer face-to-face interactions, marital satisfaction can decrease for some couples but increase for others (Czechowsky, 2008).

Work-related factors which have a positive impact on couple relationships

Work engagement

OnePlusOne has been at the forefront of research into the impact of couple relationship quality on work engagement (defined as a positive work-related state of fulfilment that is characterised by ‘vigour, dedication, and absorption’). Their 2012 research study found that relationship quality and work engagement are positively associated with high or low levels in either, correlating respectively to high or low levels in the other.

Furthermore, work-family conflict has a stronger negative influence on both work engagement and relationship quality than family-work conflict. That is, stress from work exerts a greater negative impact on work performance and family life, compared to stress originating from family-life. However, these researchers warn, “an increase in work pressures may create a negative feedback loop for employers: as heightened work stress will likely have a negative impact on workers’ relationships at home, which can, in turn, decrease their levels of work engagement”.

This study corroborates findings from one carried out in 2001 which found that psychological engagement

(attention and absorption) in work was positively related to positive emotions at work which, in turn, was related to men’s psychological engagement in family life (Rothbard, 2001); as well as other research reporting links between work satisfaction and family satisfaction, positive parenting, and positive child outcomes (Barling, 1986) (Friedman, 2000) (Greenhaus, 1999).

Flexible working practices

Due to legislative changes, the range of flexible working practices offered by employers and their uptake has increased since the early 1990s. Flexible working practices comprise working flexible hours (including a compressed week), working from home, working part-time and job-sharing.

Research indicates strongly that there is a positive link between flexible working patterns and improved work-life balance, reduced stress levels, improved performance of employees, improved employee relations, higher levels of employee commitment and motivation, reduced absenteeism and increased productivity (Swan, 2005b) (Burnett, 2010) (Gatrell, 2008) (BIS, 2011).

Other studies have shown that flexible working arrangements (in particular flexible time schedules and compressed work week schedules) can result in increased job satisfaction and reduced staff turnover (McNall, 2010) (IOD/UNUM, 2008) (BCC, 2007) (CIPD, 2005) (EHRC, 2009). Other studies, however, suggest that informal work support, such as a supportive supervisor, is more important in reducing work-family conflict than formal provision for flexible working patterns (Behson, 2005) (Cook, 2009). Furthermore, a supervisor supportive of family life has been found, more generally, to be associated with less work-family conflict and an improved home life (Allen, 2008).

OnePlusOne’s research shows that whereas working flexibly is associated with higher work engagement it is linked to slightly lower levels of relationship quality (possibly on account of working flexibly resulting in higher degrees of conflict between work and family-life as the boundaries become blurred) (Burnett, 2012).

Supporting couple relationships: a spectrum of employer approaches

The research highlighted in this briefing strongly supports the view that business and employers can influence the relationship quality and other aspects of the home lives of their employers both positively and negatively. This view is strengthened by OnePlusOne’s study (Burnett, 2012) which found that work-family conflict (rather than family-work conflict) had the strongest link to work engagement and relationship quality. It seems clear therefore it is employers who are in the best position to address this area, since the conflict stems from work.

Activities which employers can engage in to support employees’ relationships range from largely preventative approaches to those which seek to address relationship problems which are established and/or long-standing. The former comprise activities such as building up strong employee networks, providing parenting support (e.g. providing extra help for new fathers during the period after the birth of a child), helping to identify boundaries between work and home (in order to reduce the risk of these being eroded either by employers or employees), and the provision of flexible working practices which are mutually beneficial to employees and employers; while the latter includes the provision of couple counselling and therapy.

However, although almost 95% of HR managers who responded to a survey conducted by the Tavistock Centre for Couple Relationships in 2013 either agreed or strongly agreed that employees’ couple relationships difficulties affect work performance, relatively few examples of UK employers taking steps to support employees’ relationships exist, with the availability of relationship counselling through employers remaining extremely patchy (TCCR, 2013) with the majority of employers referring employees to individual therapy (TCCR, 2013) despite evidence suggesting that individual counselling is less effective for relationship difficulties than couple approaches (Beach, 1992) (Emanuels-Zuurveen, 1992).

Conclusion and policy implications

The Relationships Alliance believes that the research highlighted in this briefing presents a strong case as to why it is in the business interests of UK employers to do more to support the relationships of those that they employ.

After all, employers can often struggle to find high calibre employees. Given the wealth of research which establishes links between work stress and lower job satisfaction, greater likelihood of wanting to find new employment, and greater likelihood of burnout, it would seem to be firmly in the interests' of employers (and of course the economy as a whole) to put in place a variety of measures and approaches which will support the couple and family relationships of those they employ.

It is a reasonable supposition however – and certainly the results from TCCR's 2013 survey indicate would support this – that the majority of employers do not see the relationships of their employees as their concern. And yet the more that chief executives and HR managers recognise relationship quality as an asset that needs to be maintained, rather than seeing the relationships of their employees as a private realm into which they must not enter, the more that they can do to foster in their employees the skills necessary to maintain strong and stable relationships – skills which also happen to be extremely useful at work.

Relationship skills need therefore to be seen as aptitudes which employers can invest in. Acting to alleviate pressures at work can help establish a virtuous cycle that benefits both employers and employees. As with the relationship support generally, a spectrum of support should be available ranging from flexible working practices which are of benefit to employer and employee alike, line-management which acknowledges and actively supports the importance of employees’ relationships to their working lives; to couple counselling and therapy services available through HR departments/employee assistance programmes which aim to support employees who are encountering difficulties in their couple relationships.

References

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Relationship Advice

Summary

Mental health disorders are a cause and a consequence of relationship distress; the bi-directionality of the link between the two is relatively unacknowledged however in policy circles and professional practice
Improving the quality of the couple relationship, research shows, is beneficial where mental health disorders and relationship distress co-exist
The treatment of relationship distress has the potential alleviate up to 30% of cases of major depression, according to research
Interventions which aim to treat mental health issues in the context of relationship distress are only minimally available under the NHS
Unresolved and poorly managed conflict between parents can create long-term emotional and behavioural problems in children
The quality of the parental couple relationship has an impact on the development of attachment in (and potentially therefore the mental health of) infants and young children

Adult mental health and the couple relationship – what does the research say?

Common mental health problems have been found to be more prevalent in people who are experiencing relationship distress than those who are happier in their relationships (Whisman and Uebelacker, 2003). Links between rarer mental health conditions, such as personality disorder, and couple relationships have also been found.

In terms of magnitude, people who live in distressed and troubled relationships are three times more likely to suffer from mood disorders (e.g. depression), two and a half times more likely to suffer from anxiety disorders, and twice as likely to suffer from substance use disorders as people who do not experience such relationship distress (Whisman and Uebelacker, 2003). These levels of associations, the researchers point out, are ‘generally quite large’.

Depression/mood disorders

Authors of a study conducted in 1999 of over 900 married individuals

who, at the start of the study were classified as not having major depression, concluded that ‘20% to 30% of new occurrences of major depressive episodes could be prevented if marital dissatisfaction could be eliminated’ (Whisman, 1999). Researchers who conducted a meta-analysis published in 2001 found marital dissatisfaction to be ‘associated with both depressive symptoms and diagnostic depression’ (Whisman, 2001) and a mean correlation between marital distress and major depression of .66 (that is, 66% of the variation in major depression is explained by the variation in marital distress – a strong correlation in statistical terms).

Furthermore, a study of nearly 5,000 adults has shown that the quality of a person's relationships with their partner predicts the likelihood of major depression disorder in the future (Teo, 2013). This research found that one in seven adults with the lowest-quality relationships were likely to develop depression as opposed to one in 15 with the highest quality relationships; and that people with unsupportive partners were significantly more likely to develop depression, whereas those without a partner were at no increased risk.

Little data is available from the UK regarding the prevalence of depression (or indeed other mental health problems) among people experiencing relationship distress. However, the Tavistock Centre for Couple Relationships recently analysed data on its clients and found that, of 7,455 people who accessed its couple therapy services, 71 per cent were suffering with a mild-to-severe depressive illness (based on CORE scores at intake transformed to Beck Depression Inventory scores).

Anxiety

While one literature review conducted in 2005 found no conclusive link between marital relationship and anxiety disorders in adults (Goldfarb, 2007), most research in this field does support a link. For example, a recent study which examined 33 couples in which the wife was diagnosed with an anxiety disorder found “an association between anxiety disorders and relationship distress consistent with previous research” (Zaider, 2010).

The previous research which that paper refers to includes studies which have found both husbands’ and wives’ panic disorders to be linked to marital quality (McLeod, 1994), marital satisfaction to be lower among people with generalized anxiety disorder (GAD) than those without (Whisman, 2000) and that patients with anxiety disorders perceive their mental health to be significantly poorer than those without anxiety disorders (Olatunji, 2007). This last study appears to concur with findings from a study comparing 52 individuals seeking treatment for GAD with 55 without the disorder which showed that couple relationships was by far the area which the most patients reported as being problematic (Henning, 2007). This chimes with findings from another study which showed that the level of hostility and criticism evident during interactions between patients and their partners was highly predictive of the outcome of treatment for GAD (Zinbarg, 2007).

Personality disorders

Personality disorders have adverse consequences on intimate relationships according to research (e.g. Truant, 1994). Of these disorders, it is suggested that borderline personality disorder may demonstrate “particularly strong associations with relationship functioning, insofar as it is characterized by impulsivity, affective instability, and inappropriate or intense anger, features that carry importance in an interpersonal context” (Whisman, 2009).

In relation to intimate partner violence, studies report incidence rates of personality disorders to be 80-90% in male perpetrators of this kind of abuse, compared to estimates in the region of 15-20% in the general population (Dutton, 2007); studies have shown that, of the personality disorders, antisocial personality disorder is the one most highly associated with intimate partner violence carried out by men (Johnson, 2006).

The couple relationship and child mental health – what does the research say?

In ChildLine’s most recent annual report, ‘family relationships’ – defined as ‘conflict/arguments with family members, parents’ divorce/separation’ – were identified as the leading reason why children contacted the service during that year (ChildLine, 2015).

This data echoes that from a recent survey of over 4,500 children across 11 child and adolescent mental health services (CAMHS), in which ‘Family Relationships Problems’ were reported by CAMHS clinicians as being the biggest presenting problem (Wolpert and Martin, 2015).

While the term ‘family relationships’ encompasses a number of different relationship dynamics, the relationship between a child’s parents is likely to account for a significant proportion of those having a troubling impact on children.

Indeed, UK research analysing Millennium Cohort Survey data shows there to be a clear link between parents’ relationship quality and children’s behavioural problems, even when other potentially confounding factors are taken into account: ‘parents’ relationship quality is clearly related to children’s externalizing problems at ages 3 and 5 years’ (Garriga and Kiernan, 2015).

Garriga and Kiernan’s findings are congruent with a wealth of research showing the negative impact of interparental conflict on children. The Early Intervention Foundation’s 2016 review - What works to enhance inter-parental relationships and improve outcomes for children (Harold et al., 2016) - sets out the evidence base in this area.

In summary, however, research shows that as opposed to ordinary difficulties and rows between couples which are managed by them and worked out (and which can model how strong disagreements can be managed without resulting in the loss of love and affection (Cummings et al, 1991)) couple conflict which is frequent, intense and poorly resolved is very harmful to children’s mental and physical health (Cowan and Cowan, 2002; Harold and Leve, 2012).

In response to this kind of conflict, babies may become agitated, and children under 5 years may respond by crying, acting out, freezing or withdrawing from or intervening in the conflict. Older children may show a range of distress including anxiety, depression, aggression, hostility, anti-social behaviour, and perform worse academically than their ability level (Harold et al, 2007). Conflict does not just have to be violent or outwardly expressed; conflict that is characterised by deliberate coldness and withdrawal can affect children, potentially creating long-term emotional and behavioural problems (Cummings and Davies, 1994; Amato, 2001). Conflict in which children feel blamed, responsible, or at risk of it turning onto them is the most damaging of all (Grych et al, 2003).

The impact of couple relationship quality and functioning on attachment and infant mental health

Children whose needs are met reliably and consistently develop a secure attachment pattern linked to subsequent greater social competence (NICHD Early Child Care Research Network, 2006), conscience development (Kochanska, 1997), fewer internalizing and externalizing problems (Lyons-Ruth et al, 1997), better problem-solving abilities, and greater competence with peers (Sroufe, 1985; Elicker, 1992).

On the other hand, children whose experience of care is less reliable and sensitively responsive can develop an insecure attachment style which is associated with a lower ability to form and sustain stable and supportive relationships as adults, and they are likely to have difficulties expressing or regulating their feelings, adding to the stress within the family. As they get older they may find it more difficult to use potentially supportive social relationships, and can be vulnerable to low self-esteem and breaking down under stress (Sroufe et al, 1999). Chaotic and arbitrary experiences of care can lead to a disorganised attachment style in which relationships are hard to make sense of, and impulse control is under-developed leading to considerable difficulties in later life, including the perpetuation of violent or abusive relationships.

Many things can affect parents’ abilities to maintain good, sensitive childcare, but one of them is the quality of their couple relationship (relationship quality, it should be noted, is highly correlated with maternal depression (Mamun, 2009)). In addition to alleviating depression, improving relationship quality helps improve the attachment security of children, even in the face of pre-existing attachment insecurity in the mothers (Das Eiden et al, 1995), and this is particularly important when parents are living apart (Finger et al, 2009). In addition, good relationships between the adult couple are associated with good relationships between the baby and the father in particular, helping to develop secure attachment styles in the infant (Frosch et al, 2000). It is also reported that relationship conflict leads to less positive interactions between fathers and their babies, and less attachment security as a result (Owen and Cox, 1997), and conflict between partners before birth seems to have a similar result (Yu et al, 2012). See What do couple relationships have to do with infant mental health and secure attachment (TCCR, 2012) for overview of research in this area.

Policy landscape

While it is important that the Government’s 2016 mental health taskforce report identified the importance of ‘having friends, opportunities and close relationships’ for mental health, as well as noting that good mental health services recognise the importance of strong relationships (Mental Health Taskforce, 2016), the links between mental health and relationship quality do not feature prominently in the report.

And while the Government’s strategy for improving children’s mental health, Future in Mind (Department of Health, 2015), recommends that ‘professionals who work with children and young people are trained in child development and mental health, and understand what can be done to provide help and support for those who need it’, it makes no mention of the links between parental relationship quality and children’s mental health.

However, the publication of the Early Intervention Foundation’s review on interparental conflict and children’s outcomes will prove an important counterbalance to this omission we hope (Harold et al., 2016).

The Government is currently writing a Life Chances Strategy which, we believe, presents an important opportunity to ensure that approaches to parenting, mental health and the couple relationship are at last integrated (for an example of an effective, evidence-based intervention which brings these areas together, see our briefing on the results of TCCR’s Parents as Partners programme (TCCR, 2016)).

Support for this view comes from the authors of an analysis of data from the Millennium Cohort Study in which they state that policy which focuses on either the quality of adult couple relationships or mother-child relationships ‘to the exclusion of the other, is likely to be less effective in improving children’s well-being’ (Kiernan & Garriga, 2015).

As this briefing sets out, evidence has long been collected which links difficulties with intimate relationships with a range of mental and physical health problems in both adults and children (e.g. Whisman and Uebelacker, 2003). But while there is evidence to show that couple-focused interventions to treat mental health problems such as depression are more acceptable to patients than approaches such as anti-depressant medication (Leff, 2000) little is being done currently to ensure that such approaches are made more widely available.

For while the recommendation made by NICE in 2009 that couple therapy for depression be made available to treat depression in ‘people who have a regular partner and where the relationship may contribute to the development or maintenance of depression’ was welcome, the gulf between rhetoric and reality is very wide, with this intervention being available in only half of IAPT services (HSCIC, 2015), and accounting for less than 1% of all sessions delivered in IAPT nationally (HSCIC, 2015).

Policy implications

There is an urgent need to ensure that approaches to parenting, mental health and couple relationships are integrated; the forthcoming Life Chances Strategy represents a key opportunity to make progress on this area.
There needs to be much greater awareness among practitioners working in child and adolescent mental health settings, as well as other frontline services such as health visiting and children’s centres, of how parental couple functioning and dynamics can lead to children’s mental health problems; those responsible for training these practitioners should also ensure that they are either enabled address parental relationship issues in couples directly or trained to be able to identify relationship issues in their clients and signpost to relationship support services when appropriate.
There also needs to be much greater awareness among practitioners working with the adult population of the impact of relationship functioning on the development and maintenance of mental ill health (for example, material contained in Supporting Couple Relationships in General Practice, an online CPD module devised by One Plus One which help GPs recognise when relationship issues are present in patients and identify their potential impact on health, should form part of standard GP training).
The IAPT programme must provide choice of a person’s preferred NICE-recommended therapy and expand the provision of couple therapy for depression.

References

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[1] Because of the legal status of marriage, the majority of research studies in the field of relationship distress have collected data on married relationships rather than other relationships. It is likely however that similar associations to those found to exist by research looking at marital quality and other factors are evident in other relationships, such as cohabiting partnerships. Indeed the Relationships Alliance views all couple relationship distress as having a potentially deleterious impact on mental health.

Couple relationships and health and wellbeing in later life: a policy briefing from the Relationships Alliance. (Click here to download the PDF file)

Summary

The older couple relationship has been largely invisible at all levels – policy-making, commissioning, local service provision.
Indeed, while we have long recognised for more the importance of family relationships in outcomes for children (and this is reflected in health and social care policy) at the other end of the lifespan, in older adults’ services, the importance of relationships of many decades’ standing may be ignored, and partners separated. The human cost of this is immense and, as research indicates, is reflected in poorer outcomes.
Over and above the cost in emotional terms, there is a significant economic cost attached to our failure to sufficiently target help to relationships which, if they could hold together, might provide care and containment that is otherwise very expensive to provide in institutional settings.
There are perhaps signs of the beginnings of change, for example in older people’s IAPT and approaches to dementia care which focus on the couple relationship, but these are relatively sparse at present.

Commitments made by the Coalition Government in 2010 to ‘put funding for relationship support on a stable, long-term footing, and make sure that couples are given greater encouragement to use existing relationship support’ were naturally welcomed by all those who recognise the importance of good quality relationships to the health and wellbeing of children, adults and wider society.

While recent policy initiatives have tended to focus on couples who are about to have or have just had a child, or couples who are struggling with young children (The Three of Us[1] and CanParent[2], for example), relationship support is relevant to all couples, whatever their life stage and the Relationships Alliance aims to adopt a cradle to grave approach.

With life expectancy increasing by five hours per day, and the number of people aged over 65 set to increase by 51% between now and 2030, many more couples will not only be facing challenges and encountering the kinds of difficulties which relationship support services are set up to address but there will be many more couples where one or more partner has a disability. The number of people in England with moderate or severe disabilities is projected to increase by 32% by 2022 (Nuffield Trust, 2012) and there will be over 50% more people with three or more long-term conditions in England by 2018, compared to 2008 (House of Lords, 2013). Both of these factors have a significant impact on couple relationship quality and functioning.

So while it is crucial that relationship support services are available to, and accessed by, young couples starting out in life together as well as couples across the working age span (support which we might, in terms of its preventative potential, think of as supporting couple relationships for later life), it is equally fundamental that we support couple relationships in later life itself. After all, personal relationships are a key factor in determining how happy our later years will be, with 9 out of 10 people believing that their relationship with their partner is very important to their happiness in retirement, a recent poll has shown (Relate, 2013).

How does our failure to support relationships during adulthood and in later life manifest itself?

Loneliness

While it is important to acknowledge that not everyone who lives alone is lonely (and, indeed, that not everyone who is lonely lives alone), research nevertheless shows that the absence of intimate relationships in particular fosters loneliness, but also highlights that it is the quality of relationships, not the quantity, that matters most to people (Kraus, 1993).

By 2033 4.8 million people over 65 will live alone (Communities and Local Government, 2010). Given that the percentage of divorce in the over 65s has doubled in the decade 2001-11, it is clear that significant numbers of people over 65 are projected to be living alone due to relationship breakdown. Translating the Government's aspirations – that couples are given greater encouragement to use relationship support services – into reality has the potential to reduce the numbers of older people who are lonely by lessening the incidence of relationship breakdown earlier in life.

Widening the uptake of relationship support services by people of working age and in later life may not only reduce the numbers of elderly people living alone however. It could also – given that relationship quality is associated with improved health in a range of areas – result in reduced levels of illness for those suffering from long-term physical health conditions and, as a consequence of this, improved well-being for their partners.

Physical health and long-term conditions

Getting older is not of course an illness in itself; nevertheless, it is associated with a range of long-term conditions such as cardiovascular disease, arthritis and depression. Links between relationship quality and long-term conditions are well-established (e.g. Kiecolt-Glaser, 2001). Research on cardiovascular disease, for example, shows that marital stress may increase the risk of recurrent coronary events (Orth-Gomer, 2000), while marital quality predicts patient survival among patients with chronic heart failure (Coyne, 2001). The quality of couple relationships also has a remarkable impact on survival rates after bypass surgery, with married people being 2.5 times more likely to be alive 15 years after coronary artery bypass grafting (CABG) than those who are not married, and those in high-satisfaction marriages being 3.2 times more likely to be alive 15 years after CABG compared with those reporting low marital satisfaction (King, 2011).

In relation to blood pressure, people with mild hypertension who report higher levels of marital satisfaction exhibit decreased left ventricle mass and lower diastolic blood pressure after 3 years than people with lower levels of marital satisfaction (Baker, 2003). In addition, relationship quality is a better predictor of daily blood pressure, affect and stress than partner status, with high relationship quality being linked to lower blood pressure (Grewen, 2005). Similarly, high marital quality is associated with lower ambulatory blood pressure, lower stress, less depression, and higher satisfaction with life; but that single individuals have lower ambulatory blood pressure than their unhappily married counterparts (Holt-Lunstad, 2008).

Depression, well-being and mental ill health

In the same way that research has shown that poorer relationship quality is associated with poorer cardiovascular health, research has shown that the quality of a person's relationships with a partner predicts the likelihood of major depression disorder in the future (Teo, 2013). And while the implications of these kinds of studies are largely to be still acted upon at a policy or clinical level, just as significant are findings from research which indicate that the physical and psychological health of older couples is dynamically linked. For example, researchers have found strong associations between depressive symptoms (unhappiness, loneliness, restlessness) and functional limitations (the physical inability to perform basic tasks of everyday living) in couples, with each spouse’s symptoms waxing and waning closely with those of their partner’s (Hoppmann, 2011). Such findings show how interdependent emotionally and physically older couples are; and highlights the need for a health and social care system that focuses on a patient and their significant relationship and not solely on an individual patient in isolation.

Furthermore, working on older people’s wellbeing is actually preventative for people developing depression in the longer term. It is encouraging therefore that ‘No health without mental health’, the Government's mental health strategy (Department of Health, 2011), supports both the provision of psychological interventions for people with long-term conditions and psychological interventions to improve older people’s mental health through the Improving Access to Psychological Therapies (IAPT) programme.

IAPT provides support predominantly to individuals rather than couples; however, given that some studies have estimated that over 60% of those with depression attribute relationship problems as the main cause for their illness (O‘Leary, Riso & Beach, 1990; Rounsaville et al., 1979) and that a meta-analysis has found marital dissatisfaction to be ‘associated with both depressive symptoms and diagnostic depression’ (Whisman, 2001), it is concerning that IAPT services have not seen the numbers of older people coming forward that it had hoped (only 5% of the 500,000 seen in IAPT have been older people). Much more work therefore needs to be done to increase the value put on late life relationships.

The health of carers

An area related to that explored in the previous paragraphs is the high incidence of stress resulting from the burden and isolation experienced by carers (950,000 people over 65 are carers (Carers Trust, 2013)). Carers who provide substantial amounts of care are over twice as likely to have mental health problems than those who provide more limited amounts, and over a quarter of those providing over 20 hours a week have mental health problems (Singleton, 2002).

Research also shows that loss of intimacy is associated with carer spouse depression, and that low levels of positive interaction between the partners in the marriages of people with dementia predict the move to residential care, and the death of that spouse with dementia two years later (Wright, 1991) (Wright, 1994).

Furthermore, research shows that closer relationships between carer and the person with dementia are associated with slower decline in Alzheimers’ Disease, and this effect is highest for couple relationships (Norton, 2009).

The care needs and health of people with dementia

In dementia, the importance of the couple relationship is thrown into sharp relief. 800,000 people are estimated to have dementia, according to the Alzheimer’s Society, while one in twenty-five between the ages of 70-79 will develop it, with this ratio increasing to one in six after the age of 80.

Research shows that what might look like small psychological gains in a condition that is progressive and incurable can nevertheless have very important consequences: studies show that the training of carers delays the admission to nursing home by an average of 20 months (Brodaty, 1997) and providing carers with emotional support delays admission to residential care by an average of 500 days (Mittelman, 2006).

Society

An inadequate focus on the couple relationship in later life makes for a more poorly connected society. Research shows that parents’ relationships with their adult children are negatively affected by divorce, which means that older parents get less support (Kalmjin, 2012), something which is particularly worrying given the doubling in the percentage of divorce in the over 60s between 2001 and 2011 (ONS, 2011). Conversely, the loss of relationship with an older parent translates into a reduced availability of kinship care from grandparents (that is, a grandparent with whom an adult son or daughter has a difficult relationship is less likely to be someone whom that son or daughter can call on to help lighten the load when they are looking after small children). Indeed, it is clear that, at all stages of life, relationship distress has consequences that reach beyond the couple, particularly affecting children and grandchildren.

What interventions exist to support couple relationships in later life?

Older people’s IAPT

IAPT data since 2008 reveals that older people benefit as much, if not more, than younger people from this programme (and older people are more likely to complete the intervention). One of the NICE-recommended interventions available through this service is couple therapy for depression. This intervention is designed to treat mild to moderate depression where there is a distressed couple relationship that appears to be a factor in instigating, maintaining, or re-precipitating the depressive symptoms in one partner. It is also the intervention of choice where a close relationship might be a necessary support for treatment adherence (Hewison, 2011).

Living Together with Dementia: A psychosocial intervention for couples where one partner has a dementia

Developed by The Tavistock Centre for Couple Relationships with support from Camden Council’s Innovation Fund, this is a new approach to working with couples where one partner has a dementia. It comprises a brief, structured intervention, using everyday activities, delivered in participants’ homes; ‘Flip’ cameras are used to videotape the partners doing ordinary activities around the house and selected interchanges then played back to the couple as a way in to addressing dynamics between them.

The approach aims to increase shared activity, emotional contact and understanding between the partners - and to counter the tendency towards withdrawal and loss of contact, or the acting out of frustration and anger. The aim is to help people with dementia to manage the trauma of the diagnosis, the loss and the changes it brings and to maintain, or recover, the protective aspects of the relationship.[3]

Changing the culture of care for people with dementia

Acceptance and acknowledgment that older people with dementia have a need for intimacy, love and sexual expression represents something of a challenge to the care sector. However, a guide on the topic of dementia, sexuality and relationships in care homes which was sponsored by the Department of Health and published in 2011 hopes to change this (ILCUK, 2011).

The guide covers the need for those providing care for older people with dementia to promote a culture of acceptance, dignity and privacy for all residents (while remembering not all relationships will be heterosexual), to educate care workers in their employment on the sexual and intimate needs of residents and to include, if possible and if volunteered, the social and sexual history of residents in care plans. Very few care plans address the sexual needs of individual clients, despite the benefits to person-centred care of this aspect of dementia planning; and many couples may wish to maintain a sexual relationship, experiencing sexual intimacy as a source of comfort, reassurance and mutual support (Bouman, 2007).

This briefing was produced by the Tavistock Centre for Couple Relationships on behalf of the Relationships Alliance. The Relationships Alliance, a corsortium comprising Relate, Marriage Care, One Plus One and the Tavistock Centre for Couple Relationships, exists to ensure that good quality personal and social relationships are more widely acknowledged as central to our health and wellbeing

References

Baker, B., Szalai, J. P., Paquette, M., & Tobe, S. (2003). Marital support, spousal contact and the course of mild hypertension. Journal of Psychosomatic Research, 55, 229–233.

Bouman W. P. (2007). Sexuality and Dementia. Geriatric Medicine. 35, 5, 35–41.

Brodaty, H., Gresham, M., & Luscome, G., (1997). The Prince Henry Hospital dementia caregivers training programme. International Journal of Geriatric Psychiatry 12, pp183-193.

Carers Trust (2013) Key facts and statistics

Communities and Local Government (2010). Updating the Department for Communities and Local Government’s household projections to a 2008 base. Final Report.

Coyne, J. C., Rohrbaugh, M. J., Shoham, V., Sonnega, J. S., Nicklas, J. M., & Cranford, J. A. (2001). Prognostic importance of marital quality for survival of congestive heart failure. American Journal of Cardiology, 88, 526–529.

Department of Health (2011). No Health Without Mental Health: a cross-government mental health outcomes strategy for people of all ages

Grewen, Karen M., Girdler, Susan S., Light, Kathleen C. (2005). Relationship quality: effects on ambulatory blood pressure and negative affect in a biracial sample of men and women. Clinical Methods and Pathophysiology, 10,3, 117-124.

Hewison, D. (2011). A guide to couple therapy for depression. Healthcare Practitioners Journal, April 2011, 32-33

Hoppmann, C., Gerstorf, D., Willis, S., & Schaie, K. W. (2011). Spousal interrelations in happiness in the Seattle Longitudinal Study. Developmental Psychology, 47, 1-8.

Holt-Lunstad, J., Birmingham, W. A., Light, K. C. (2008). Influence of a ‘warm touch’ support enhancement intervention among married couples on ambulatory blood pressure, oxytocin, alpha amylase, and cortisol. Psychosomatic Medicine 70(9), 976-85.

House of Lords Select Committee on Public Service and Demographic Change. (2013) Report of Session 2012–13 Ready for Ageing? Nuffield Trust, Reforming social care: options for funding, May 2012.

ILCUK (2011). The last taboo: A guide to dementia, sexuality, intimacy and sexual behaviour in care homes. International Longevity Centre – UK

Kalmijn, M. (2012) Long-Term Effects of Divorce on Parent–Child Relationships: Within-Family Comparisons of Fathers and Mothers. European Sociological Review, July, 2012

Kiecolt-Glaser, J. K., & Newton, T. L. (2001). Marriage and health: His and hers. Psychological Bulletin, 12, 472–503.

King K, B., Reis H. T. (2011) Marriage and long-term survival after coronary artery bypass grafting. Health Psychology, 22

Kraus, L. A., Bazzini, D., Davis, M., Church, M., & Kirchman, C. M. (1993). Personal and social influences on loneliness: The mediating effect of social provisions. Social Psychology Quarterly, 56, 37-53.

Mittelman M. S., Haley W.E., Clay O.J., Roth D.L. (2006). Improving caregiver wellbeing delays nursing home placement of patients with Alzheimer’s disease. Neurology 14;67(9), 1592-9.

Norton, M.C., Piercy, K.W., Rabins, P.C., Green, R.C., Breitner, J.C.S., Ostbye, T., Corcoran, C., Welsh-Bohmer, K.M., Lykefsos, C.G., & Tschanz, J.T. (2009) Caregiver-Recipient Closeness and Symptom Progression in Alzheimer’s Disease. The Cache County Dementia Progression Study. Journal of Gerontology: Psychological Sciences, 64B (5), 560-568.

Office for National Statistics (ONS) (2011). Divorces in England and Wales – 2011. http://www.ons.gov.uk/ons/rel/vsob1/divorces-in-england-and-wales/2011/stb-divorces-2011.html

O’Leary, K., Riso, L. P., Beach, R. H. (1990). Attributions about the marital discord/depression link and therapy outcome. Behavior Therapy, 21, 4, 413-422

Orth-Gomér, K., Wamala, S. P., Horsten, M., Schenck-Gustafsson, K., Schneiderman, N., & Mittleman, M. A. (2000). Marital stress worsens prognosis in women with coronary heart disease: The Stockholm Female Coronary Risk Study. Journal of the American Medical Association, 284, 3008–3014.

Partridge, L. (2009) – Rejuvenating Ageing Research. Academy of Medical Sciences

Relate (2013) - http://www.relate.org.uk/news/102/index.html

Rounsaville, B. J., Weissman, M. M., Prusoff, B. A., Herceg-Baron, R. (1979). Marital disputes and treatment outcomes in depressed women. Comprehensive Psychiatry, 20, 5, 483-490

Teo, A. R., Choi, H., Valenstein, M. (2013). Social Relationships and Depression: Ten-Year Follow-Up from a Nationally Representative Study. PLOS ONE, 10.1371/journal.pone.0062396

Wright, L. (1991). The impact of Alzheimer’s disease on the marital relationship. The Gerontologist, 31, 224-326.

Wright, L. (1994) Alzheimer’s Disease afflicted spouses who remain at home: Can human dialectics explain the findings? Social Sciences and Medicine, 3, 8, 1037-1046.

Young, H., Grundy, E. (2009). Living Arrangements, Health and Well-Being, Understanding Population Trends and Processes, 1, 127-150

[1] http://www.the3ofus.org.uk/the-3-of-us/

[2] http://www.canparent.org.uk/

[3] For further information about this approach, see: http://www.tavistockrelationships.org.uk/relationship-help/living-together-with-dementia

Policy briefings

Children's mental health and inter-parental conflict

Why does couple therapy not form part of the standard CAMHS offer?

Developing practice

Case study 1:

Case study 2:

Next steps

References

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