Why should primary care practitioners be interested in the adult couple relationship, something that seems in-between the needs of individuals to have their care needs recognised and the needs of families to support parenting and protect and nurture healthy children? Aren’t couple relationships best seen as a matter for the partners involved, rather than as a focus for interventions? The short answer is that a focus on the adult couple relationship can be one of the most effective ways of supporting and helping individuals, parents, and children. There is now a considerable body of evidence that points to the fundamental importance of adult couple relationships for a variety of physical and mental health outcomes for both adults and children. The evidence comes from a variety of sources: randomized controlled studies of therapies for specific disorders; naturalistic studies of the impacts of clinics that offer help to couples (Hewison et al., Reference Hewison, Casey and Mwamba2016); and community-based epidemiological surveys that look at correlations and prevalence. Much comes from the study of marriages and some from committed relationships, whether gay or straight, but all highlight the interdependency of good relationships and well-being.Footnote 1
Couple relationships and adult mental health
Whisman and Uebelacker (Reference Whisman and Uebelacker2003) have indicated that particular psychiatric disorders are more likely in people who are martially distressed as opposed to those who are not. In their large community survey in the United States they noted that people who live in distressed and troubled relationships are three times more likely to suffer from mood disorders, two and a half times more likely to suffer from anxiety disorders, and twice as likely to suffer from substance use disorders as non-martially distressed people. They suggest that improving the quality of the couple relationship is of value in a range of cases where there are coexisting mental health disorders and relationship distress, saying that the treatment of relationship distress could alleviate up to 30% of cases of major depression (Whisman and Bruce, Reference Whisman and Bruce1999). In the United Kingdom this has been taken up in the national health service with the National Institute for Health and Clinical Excellence recommendation of couple therapy as a suitable therapy for treating depression in Improving Access to Psychological Therapies services (Hewison et al., Reference Hewison, Clulow and Drake2014). It is clear that depression and couple stress and conflict have bi-directional impacts on each other (Davila et al., Reference Davila, Karney, Hall and Bradbury2003) and that individual treatments such as Cognitive Behavioural Therapy do not improve relationships even though they help depression. Treating only the individual means that the depression-aggravating relationship setting does not change, rendering individuals more likely to have a subsequent relapse including those who have already been successfully treated for depression (whether by individual psychotherapy or psychopharmacological treatments) (Whisman, Reference Whisman2001). In fact, relationship distress also has a detrimental impact on how well treatments work in the first place (Denton et al., Reference Denton, Carmody, Rush, Thase, Trivedi, Arnow, Klein and Keller2010; Foran et al., Reference Foran, Whisman and Beach2015).
Research has also shown that within the family and close friendship network, it is the couple relationship that has the most impact on the prevalence of major depression (Whisman et al., Reference Whisman, Sheldon and Goering2000), and the longer the couple has been distressed, the stronger the link to depression (Kouros et al., Reference Kouros, Papp and Cummings2008). Be et al.’s (Reference Be, Whisman and Uebelacker2013) 23-year study of somatic symptoms and relationship disagreements showed that levels of each were elevated where there was depression as compared with families without a depressed spouse, and life satisfaction – especially for women – is impaired by relationship distress. This finding echoes other studies such as Beach et al. (Reference Beach, Katz, Kim and Brody2003) and the work of Cano and O’Leary (Reference Cano and O’Leary2000) showing that humiliating events for women in marital relationships (infidelities and threats of separation) are six times more likely to result in an episode of major depressive disorder than in a control group where there was not such humiliation. Beach et al. (Reference Beach, Kim, Cercone-Keeney, Gupta, Arias and Brody2004) have shown that incidents of physical aggression aimed at wives in heterosexual relationships also – unsurprisingly – increase the risk of subsequent depression.
Couple relationship distress can lead to a lowering of social and functional skills, in addition to depression, making it harder to recover (Segrin, Reference Segrin2000; Choi and Marks, Reference Choi and Marks2008). Although this reduction in social skills is associated with depression, a 10-year-community study by Teo et al. (Reference Teo, Choi and Valenstein2013) showed that social isolation alone was not predictive of future incidents of depression, whereas poor quality of relationships with spouses, and to a lesser extent with family members – but not with friends – was predictive of future incidents of depression 10 years later. People with a lot of relationship strain were more than twice as likely to have an episode of major depression as those with little relationship strain. This effect occurred even if there had not been a prior history of depression, with difficulty in relation to a spouse or partner (not family members or friends) being significantly associated with future depression.
The good news is that treating relationship distress reduces subsequent health service usage by 22% (Law and Crane, Reference Law and Crane2000), with higher users (defined as having four or more visits within six months) reducing their usage of urgent care by 78% after receiving conjoint therapy (Law et al., Reference Law, Crane and Berge2003), underlining the importance of attending to the close relationships that people experiencing episodes of depression have. The London Depression study (Leff et al., Reference Leff, Vearnals, Brewin, Wolff, Alexander, Asen, Dayson, Jones, Chisholm and Everitt2000) indicated that couples preferred therapy to antidepressants, with only 15% of participants in the couple therapy arm dropping out of treatment as compared with 56.8% of those in the medication arm.
Couple relationships and postnatal depression
Both mothers and fathers can become postnatally depressed. The prevalence of postnatal depression in mothers is about 13% with a range of 3–25% of women (O’Hara and Swain, 1996), that of fathers is about 10.4%, and the two are correlated (Paulson and Brazemore, Reference Paulson and Brazemore2010; Barlow and Coe, Reference Barlow and Coe2012). Depression in either partner is associated with worse outcomes for their children (Murray and Cooper, Reference Murray and Cooper1996; Ramchandani et al., Reference Ramchandani, O’Connor, Evans, Heron, Murray and Stein2008) and depression in both partners is additionally associated with poorer adherence to good-parenting behaviours such as breastfeeding (Paulson et al., Reference Paulson, Dauber and Leiferman2006). Although not all children grow up with both parents, the Millennium Cohort Study suggests that nearly all children (>95%) are born into partnerships between parents, whether married or cohabiting (cited in Burgess, Reference Burgess2011: 6). It is clear that depressed new mothers turn to their partners for support more than anyone else including health professionals (Holopainen, Reference Holopainen2002), and that such support is associated with both lower rates of depression (Cox et al., Reference Cox, Buman, Valenzuela, Joseph, Mitchell and Woods2008) and shorter stays in hospital for mothers with pre- and post-birth psychiatric disorders (Grube, Reference Grube2004). It makes sense to have the parents’ couple relationship as an important focus when thinking about enabling the optimum family conditions for good child development.
Couple relationships and children’s mental health
We have known for decades that particular kinds of conflict between couples who are parenting are damaging to children’s mental and physical health (Towle, Reference Towle1931; Emery, Reference Emery1982; Grych and Fincham, Reference Grych and Fincham1990; Davies and Cummings, Reference Davies and Cummings1994; Harold and Conger, Reference Harold and Conger1997; Cowan and Cowan, Reference Cowan and Cowan2002; Harold and Leve, Reference Harold and Leve2012). Ordinary difficulties and rows between couple which are managed by them and worked out are not harmful to children and are a model for how strong disagreements can be managed without resulting in the loss of love and affection (Cummings et al., Reference Cummings, Ballard, El-Sheikh and Lake1991). Conflict which is frequent and intense, which never gets settled fully but just seems to chain together with the next argument, is very harmful; however, to children at all ages. Babies become agitated; under-5s respond by crying, acting out, freezing, or withdrawing from or intervening in the conflict; older children show a range of distress including anxiety, depression, aggression, hostility, anti-social behaviour, and perform worse academically than their ability level (Harold et al., Reference Harold, Aitken and Shelton2007). Couple conflict doesn’t just have to be violent or outwardly expressed: deliberate coldness and withdrawal also affects children who become at risk for long-term emotional and behavioural problems (Cummings and Davies, Reference Cummings and Davies1994; Amato, Reference Amato2001). Conflict in which children feel blamed, responsible, or at risk of it turning onto them is the most damaging of all (Grych et al., Reference Grych, Harold and Miles2003). Helping parents manage the way they express and resolve conflict is an important factor in preventing childhood distress and there is strong evidence that improving the couple relationship leads to improvements in parenting, in the parent–child relationship, and in children’s outcomes even if these other domains were not specifically targeted in the intervention and the parents are separated (Das Eiden et al., Reference Das Eiden, Teti and Corns1995; Finger et al., Reference Finger, Hans, Bernstein and Cox2009; Faircloth et al., Reference Faircloth, Schermerhorn, Mitchell, Cummings and Cummings2011).
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., Reference Frosch, Mangelsdorf and McHale2000; Wong et al., Reference Wong, Mangelsdorf, Brown, Neff and Schoppe-Sullivan2009). The converse is also true: relationship conflict leads to less positive interactions between fathers and their babies, and less attachment security as a result (Owen and Cox., Reference Owen. and Cox1997); conflict between partners before birth seems to have a similar result (Yu et al., Reference Yu, Hung, Chan, Yeh and Lai2012).
Couple relationships and physical health
The couple relationship has an important impact on physical health and well-being too (Verbrugge, Reference Verbrugge1979; Office for National Statistics, Reference O’Hara and Swain2011). The quality of the relationship affects self-perceptions of health and objective indicators of health status (Ren, Reference Ren1997; Carels et al., Reference Carels, Sczczepanski, Blumenthal and Sherwood1998). It affects adjustment to health problems and has an impact on health outcomes, including earlier mortality (Hibbard and Pope, Reference Hibbard and Pope1993; Rodrique and Park, Reference Rodrique and Park1996; Kiecolt-Glaser and Newton, Reference Kiecolt-Glaser and Newton2001). Relationship quality also affects speed of recovery and likelihood of relapse. Whisman and Uebelacker point out:
‘Taken together, the existing research suggests that people who are unhappy with their intimate relationships and have poor relationship functioning are not only more likely to have a mental or physical health problem, they are also less likely to respond to treatment for such a problem’ (2003: 13).
They indicated that there is clear evidence that conditions such as:
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∙ alcohol misuse in both male and female partners (Wilsnack et al., Reference Wilsnack, Wilsnack and Klassen1984; Romelsjo et al., Reference Romelsjo, Lazarus, Kaplan and Cohen1991; Orth-Gomér et al., Reference Orth-Gomér, Wamala, Horsten, Schenck-Gustafsson, Schneiderman and Mittleman2000; Kiecolt-Glaser and Newton, Reference Kiecolt-Glaser and Newton2001; Overbeek et al., Reference Overbeek, Vollebergh, de Graaf, Scholte, de Kemp and Engels2006; Whisman et al., Reference Whisman, Uebelacker and Bruce2006; Levitt and Cooper, Reference Levitt and Cooper2010);
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∙ cardiovascular disease (Coyne et al., Reference Coyne, Rohrbaugh, Shoham, Sonnega, Nicklas and Cranford2001; Baker et al., Reference Baker, Szalai, Paquette and Tobe2003; Gallo et al., Reference Gallo, Troxel, Kuller, Sutton-Tyrrell, Edmundowicz and Matthews2003; Grewen et al., Reference Grewen, Girdler and Light2005; Holt-Lunstad et al., Reference Holt-Lunstad, Birmingham and Jones2008; King and Reis, Reference King and Reis2011);
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∙ diabetes (Trief et al., Reference Trief, Himes, Orendorff and Weinstock2001; Fisher et al., Reference Fisher, Chesla, Chun, Skaff, Mullan, Kanter and Gardiner2004; Trief et al., Reference Trief, Morin, Izquierdo, Teresi, Starren, Shea and Weinstock2006); and
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∙ metabolic syndrome (Whisman et al., Reference Whisman, Uebelacker and Settles2010; Whisman and Sbarra, Reference Whisman and Sbarra2012; Whisman and Uebelacker, Reference Whisman and Uebelacker2012).
are linked to the quality of the couple relationship.
Conclusion
Primary care practitioners should ‘think couple’. The quality of the adult couple relationship has an important part to play in the prevention, development, treatment, recovery, and relapse-prevention of a range of major mental and physical illnesses in adults and in their children. Attending to the couple relationship should be a more mainstream activity than it is currently, because of the potential benefits for individuals, couples, and families, as well as for the management and effective delivery of scarce health resources.
