Preliminary findings
Table 2 presents detailed information about demographics, diagnoses, and treatment outcomes for each participant. Mean age of the participants was 29 years (Range: 22 to 40 years; SD = 5.98). All partners declared themselves as a couple. The length of the partnership ranged from 8 months to 3 years (M = 2.35 years; SD = 0.94). The partnerships had no discontinuations before or during the stay. Of the ten patients, three had completed a vocational training. Furthermore three had a stable home situation: Couple 5 had a common apartment, and patient 4W had her own apartment. Only couple 2 had children. They had a ten month old child, who did not live with them, as they were not its legal guardian. In addition, patient 2M had two children, with whom he had no contact.
All patients smoked and all, except patient 3W (was diagnosed with an alcohol use disorder, although she tried cocaine once) and patient 4M, used multiple substances. Of the ten patients, seven had a psychiatric comorbidity. Among these, six were additionally diagnosed with a personality disorder of the cluster B (DSM IV). All patients tested negative for Hepatitis C and three patients tested positive for Hepatitis B (both members of couple 2, and patient 3M, respectively).
The length of the stay at the ward ranged from 41 to 235 days (M = 112.3, SD = 61.24). Only couples 3 and 5 requested specialised couples therapy. None of the couples received any visits by family members, although family visits are allowed and perceived by the therapists as helpful. All participants received further therapy after treatment termination at the ward, with the exception of couple 3.
Table 2. Information about demographics, diagnoses, and treatment outcomes for each patient
Patient
|
Length of therapy in days
|
Age
|
Comorbidity
|
Follow up
|
Outcome
|
Education
|
Housing
|
Used Substances
|
Length of the partnership in years
|
Hep B
|
Hep C
|
|
1W
|
117
|
29
|
None
|
LT-Therapy
|
+
|
+
|
neg
|
H, B, C
|
3
|
neg.
|
neg.
|
|
1M
|
113
|
27
|
None
|
LT-Therapy
|
+
|
+
|
neg
|
B, H, THC, Sirdalud
|
3
|
neg.
|
neg.
|
|
|
|
2W
|
94
|
23
|
Cluster A/B
|
LT-Therapy
|
+
|
-
|
neg
|
C, H
|
2
|
pos.
|
neg
|
|
2M
|
93
|
35
|
Cluster B
|
LT-Therapy
|
+
|
-
|
neg
|
C, A, H
|
2
|
pos.
|
neg
|
|
|
|
3W
|
235
|
40
|
BPD
|
None
|
-
|
+
|
neg
|
A, (C)
|
3
|
neg.
|
neg.
|
|
3M
|
199
|
35
|
Cluster B
|
None
|
-
|
-
|
neg
|
A, H,C
|
3
|
pos.
|
neg.
|
|
|
|
4W
|
86
|
25
|
|
LT-Therapy
|
+
|
+
|
pos
|
THC, H, C
|
0,75
|
neg.
|
neg.
|
|
4M
|
100
|
26
|
ADHD
|
LT-Therapy
|
+
|
-
|
neg
|
H
|
0,75
|
neg.
|
neg.
|
|
|
|
5W
|
41
|
25
|
BPD
|
None
|
+
|
-
|
pos
|
H, C, THC, B, O
|
3
|
neg.
|
neg.
|
|
5M
|
45
|
22
|
BPD
|
None
|
+
|
-
|
pos
|
H, B, A,
|
3
|
neg.
|
neg.
|
|
Note. M = Man. W = Woman. BPD = Borderline Personality Disorder. LT-Therapy = Long-term Therapy. ADHD = Attention Deficit Hyperactivity Disorder. Cluster. A/B = Personality Disorder with mixed symptoms from the Clusters A and B (DSM IV). Substances used: H = Heroin; B = Benzodiazepine, THC = Cannabis; A = Alcohol; O = Other; C = Cocaine. Hep = Hepatitis. Education = Completed a vocational training ( + = yes, - = no).
Main findings
Psychodynamic characterization. In the following, the psychodynamic for each couple over the course of the treatment is described.
Couple 1: The couple behaved like mother and son. The female patient took the lead and organised their social life. During clinical visits, she often spoke for him, which was sometimes due to language problems. Furthermore, she often cut him short during conversations or commented on his ideas as ridiculous. The dominant affects were insecurity and subliminal anger. In countertransference, anger and concern could be felt. She wavered. On one hand, she felt good when she could support him, and on the other hand, she felt burdened because she had to organize everything. He was socially dependent on her, which increased her self-esteem.
Couple 2: The couple seemed very dissimilar. She was the driving force for the treatment, and he seemed like an impediment. She was dependent on his love, tolerated his rude behaviour, and couldn´t tell him her opinion. He took advantage of her love, and degraded her when she revolted. The dominant affects were aggression and fear of loss. In countertransference, anger, concern and his wish to save her could be felt. Primarily, she was emotionally dependent on him, whereas he was indifferent and exploitative. In several therapeutic sessions, both claimed that it was their main goal to receive custody of their child again. The couple got engaged after leaving the inpatient therapy.
Couple 3: The couple first seemed very mature, responsible and equal. Over time, it became obvious that she took care of official matters. In a crisis, the roles switched, and he protected her from suicide. During this crisis, it came to a massive confrontation with verbal and physical aggression. The dominant affects were anger and fear of loss. In countertransference, boredom and tiredness, but also pressure, could be felt. He was dependent on her concerning official matters, whereas he was the main motivating factor behind abstinence and treatment motivation. On an emotional level, she was very dependent on him, as he filled her inner void. During their treatment at the ward, they “adopted” a 17-year-old male patient who was alone at Christmas time. The couple separated after being discharged from the ward.
Couple 4: The couple appeared like mother and son. During the clinical visits, the female patient often spoke for both and corrected her partner. Sometimes she also motivated him. Both tried to make their relationship appear harmonious. It was also remarkable that both partners tried to euphemise or even repudiate the other’s negative aspects. The dominant affects were subliminal anger and fear of loss. In countertransference, boredom and tiredness could be felt. She felt good when she could support him and this bolstered her self-esteem. It seemed that he was dependent on her because she organized everything for him, whereas she was emotionally dependent on him.
Couple 5: The couple appeared and acted like Siamese twins, for whom topics were always the same. If one partner focussed on medication, so did the other. The same could be said about their mood. On the other hand, the partners also had fights, which were characterised by mental and physical abuse. Here, the male partner was submissive. The dominant affects were fury and fear of loss. In countertransference, impotence and anger could be felt. Both enjoyed that during an emotional crisis only the partner could help the other. They celebrated this as a special ability, although they also realized that this made them very dependent on each other.
Follow-up. We were able to follow-up with some patients or relatives 12 months after the discharge from the ward by phone. Couple 1 was still together and raised a family with two children. Both partners of Couple 3 died. The male was found dead, and the female committed suicide. Couple 4 separated.
Psychological symptoms. Table 3 provides the scores of the BSCL at pre- and post-treatment for each patient, except for both partners of couple 5 who did not fill out the questionnaires. Also, patient 2M did not fill out the questionnaire at post. On the level of the couples, Couple 3 seemed to benefit most with regard to symptom reductions. In couple 2 and 4 the males benefited more than the females. In particular, the men showed reductions on six or more subscales including the global severity index, whereas the women showed increases on four or more subscales as well as on the global severity index. On the individual level, five out of seven patients showed decreases on somatization, interpersonal sensitivity, depression, paranoid ideation, and psychoticism as well as on the global severity index, whereas three out of seven patients showed increases on obsession-compulsion and hostility.
Table 3. Scores of the Brief Symptom Checklist at pre- and post-treatment for each patient
Patient
|
Somatization
|
Obsession-Compulsion
|
Interpersonal sensitivity
|
Depression
|
Hostility
|
Phobic anxiety
|
Paranoid ideation
|
Psychoticism
|
GSI
|
1W
|
1.1/0.1
|
1/0.5
|
0.5/0.25
|
1/0.5
|
0.2/0.3
|
0.8/0.8
|
0.8/0.2
|
0.8/0
|
1.4/1
|
2M
|
1.4/n.a.
|
1.5/n.a.
|
0.5/n.a.
|
0.7/n.a.
|
1/n.a.
|
1.7/n.a.
|
1.6/n.a.
|
1.2/n.a.
|
1.3/n.a.
|
|
|
|
|
|
|
|
|
|
|
2W
|
0.29/0.5
|
0/0.5
|
0/1.25
|
0/0.33
|
0.2/0.6
|
0/0.6
|
0.2/0.8
|
0/0.4
|
0.15/0.55
|
2M
|
0.14/0.29
|
0.33/0
|
0.5/0.25
|
0.17/0
|
0/0
|
0.2/0.4
|
0.6/0.4
|
0.2/0
|
0.26/0.17
|
|
|
|
|
|
|
|
|
|
|
3W
|
0.57/0
|
1.17/0.17
|
1/0
|
1.17/0.17
|
0.6/0
|
1.5/0
|
0.4/0
|
0.8/0
|
0.85/0.11
|
3M
|
0.57/0.29
|
1.17/0.17
|
1/0.25
|
0.5/0
|
1/1
|
0.8/0.6
|
1/0.6
|
0.8/0.4
|
0.81/0.47
|
|
|
|
|
|
|
|
|
|
|
4W
|
2.43/2.14
|
2.17/2.83
|
1.25/3.25
|
2.33/2.33
|
2.0/3.6
|
1.8/1.4
|
1.2/2.6
|
2.4/2.0
|
2.04/2.53
|
4M
|
2.86/2.71
|
1.33/1.83
|
3/1.75
|
2.17/2
|
2.4/2.0
|
1.8/1
|
1.8/1.4
|
2.2/1.6
|
2.25/2.06
|
Note. M = Man. W = Woman. n.a. = not available. GSI = Global Severity Index.
Table 4 presents the means, standard deviations, and the effects sizes between pre- and post-treatment for women and men separately. For the men, all effect sizes were at least small in size. Large effects were found for decreased interpersonal sensitivity, depression, paranoid ideation, psychoticism, and global severity. For the women the effect sizes were also at least small in size, with the exception of obsession-compulsion and global severity. The largest effect was found for decreased somatization. However it should be noted, that the effects for the women were positive for interpersonal sensitivity, hostility, and paranoid ideation meaning that these symptoms increased.
Table 4. Means, standard deviations, and pre-post treatment comparisons on the symptomatology for women and men separately
|
|
Pre
|
|
Post
|
|
|
BSCL
|
Gender
|
M
|
SD
|
|
M
|
SD
|
|
Cohen’s d
|
Somatization
|
Women
|
1.10
|
0.95
|
|
0.69
|
0.99
|
|
-0.81
|
|
Men
|
1.19
|
1.46
|
|
1.10
|
1.40
|
|
-0.42
|
Obsession-Compulsion
|
Women
|
1.09
|
0.89
|
|
1.00
|
1.23
|
|
-0.11
|
|
Men
|
0.94
|
0.54
|
|
0.67
|
1.01
|
|
-0.37
|
Interpersonal sensitivity
|
Women
|
0.69
|
0.55
|
|
1.19
|
1.48
|
|
0.37
|
|
Men
|
1.50
|
1.32
|
|
0.75
|
0.87
|
|
-1.50
|
Depression
|
Women
|
1.13
|
0.95
|
|
0.83
|
1.01
|
|
-0.50
|
|
Men
|
0.95
|
1.07
|
|
0.67
|
1.15
|
|
-1.47
|
Hostility
|
Women
|
0.75
|
0.85
|
|
1.13
|
1.67
|
|
0.41
|
|
Men
|
1.13
|
1.21
|
|
1.00
|
1.00
|
|
-0.58
|
Phobic anxiety
|
Women
|
1.03
|
0.80
|
|
0.70
|
0.58
|
|
-0.37
|
|
Men
|
0.93
|
0.81
|
|
0.67
|
0.31
|
|
-0.53
|
Paranoid ideation
|
Women
|
0.65
|
0.44
|
|
0.90
|
1.18
|
|
0.27
|
|
Men
|
1.13
|
0.61
|
|
0.80
|
0.53
|
|
-2.89
|
Psychoticism
|
Women
|
1.00
|
1.01
|
|
0.60
|
0.95
|
|
-0.71
|
|
Men
|
1.07
|
1.03
|
|
0.67
|
0.83
|
|
-2.00
|
GSI
|
Women
|
1.11
|
0.80
|
|
1.05
|
1.05
|
|
-0.10
|
|
Men
|
1.11
|
1.03
|
|
0.90
|
1.02
|
|
-1.64
|
Note. n = 4 for women. n = 3 for men. Possible range: 0-4. BSCL = Brief Symptom Check List. M = Mean. SD = Standard deviation. GSI = Global Severity Index.