Journal of Systemic Therapies, Vol. 26, No. 4, 2007, pp.

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COUPLES AND CHRONIC ILLNESS: AN ATTACHMENT PERSPECTIVE AND EMOTIONALLY FOCUSED THERAPY INTERVENTIONS
KATHY STIELL, M.S.W. Ottawa Couple and Family Institute and Aphasia Centre of Ottawa SANDRA C. NAAMAN, PH.D. CANDIDATE University of Ottawa ALISON LEE, PH.D., C.PSYCH. Ottawa Couple and Family Institute

With advances in medical technologies the prevalence of chronic illness has increased and issues of adjustment and quality of life are receiving serious attention. This article supports the position that chronic illness unfolds in the context of an interpersonal relationship that affects and is affected by the disease process in a dynamic and reciprocal fashion. Attachment theory provides a foundation for family interventions that can be universally applied across all types of illness and can play a pivotal role in maximizing levels of family functioning while living with chronic illness. This article provides a brief review of current literature on chronic illness from an interpersonal dimension and offers an applied perspective through the presentation of two case vignettes where Emotionally Focused Therapy interventions are employed. It is proposed that EFT, informed by attachment theory, effectively addresses distress in close relationships and should become part of rehabilitation efforts and long term support programs for those people affected by chronic illness.

Although advances in medical screening technologies and interventions have been successful in prolonging the lives of many persons with chronic illness, the actual prevalence of chronic illness has increased. Now that people are living longer issues
Address correspondence to Kathy Stiell, Ottawa Couple and Family Institute, 1869 Carling Avenue, Suite 201, Ottawa, Ontario, Canada K2A 1E6; E-mail: stiell@sympatico.ca.

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of adjustment and quality of life are receiving serious attention. While it is necessary to appreciate the nature and magnitude of psychological morbidity in the patient population, the impact of chronic illness is best understood as a family problem that affects spouses and children alike (Northouse & Peters-Golden, 1993). For example, Northouse describes cancer as occurring in the context of an intense relationship that affects, and is affected by, the disease process in circular reciprocity. Elsewhere, cardiac and stroke patients are reported to do better in well-functioning families (Rohrbaugh, Shoham, Sonnega, Nicklas, & Cranford, 2001; Teasell, Foley, Salter, Bhogal, Boyona, Jutai, & Speechley, 2005), but family interventions are also described as intrusive and outside the sphere of rehabilitation (Clarke & Smith, 1999). The authors propose that family interventions that focus on close relationships can in fact play a pivotal role in maximizing levels of family functioning while living with chronic illness. Emotionally Focused Therapy (EFT) with a perspective on close relationships and grounded in attachment theory provides a clear roadmap for successful intervention with distressed families. The purpose of this article is twofold: to review current literature addressing the reciprocal dynamics found between onset of chronic illness and adjustment in the context of couples relationships and to offer an applied perspective through presentation of two case vignettes where EFT interventions are employed. REVIEW OF THE CURRENT LITERATURE More than half of the general population is affected by chronic illness and approximately one third are facing more than one condition at any given time (Alonso, Ferrer, Gandek, Ware, Aaronson, & Mosconi, 2004; Lam & Lauder, 2000). Chronic illness is defined as any long-lasting or lifelong condition that typically requires long-term management. The most prevalent chronic medical conditions are those secondary to cardiac disease, cancers, cerebrovascular accidents, chronic obstructive pulmonary disease, and diabetes. Due to its pervasive nature, any given chronic illness carries the potential of impacting a persons emotional, psychological, and interpersonal functioning. It is only recently that the interpersonal context of chronic illness has come under scientific inquiry by researchers and clinicians alike. Immediately following diagnosis with a potentially life threatening illness, patients often cite their spouse as their primary source of support. The psychological impact on patient and spouse (depression, anxiety, posttraumatic stress symptoms) can vary depending on variables such as type of diagnosis, functional implications, premorbid health status, and coping strategies (Rodrigue & Hoffmann, 1994). A salient point here, however, is that the spouse generally appears to experience similar levels of psychological distress that can equal or exceed that of his or her partner who is ill (Baider, Walach, Perry, & Kaplan de-Nour, 1998; Gotay, 1984; Hannum, Giese-Davis, Harding, & Hatfield, 1991). For example,

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partners of stroke survivors are reported to have high rates of depression, 30% in one study and 41% in a second study. In both of these studies partners also had higher rates of depression than their spouses with stroke (Sit, Wong, Clinton, Li, & Fong, 2004; Suh, Kim, Kim, Cho, Choi, & Noh, 2005). In the breast cancer population, Northouse & Swain (1987) observed that both patients and their spouses reported similar levels of distress that tended to improve slightly one month after surgery showing a mirroring effect between the couple. In another follow-up study tracking couples 18 months postsurgery, Northouse (1989) observed that, despite a decrease in distress scores over time, both patients and their partners reported significant psychological distress. In another longitudinal study of 143 newly diagnosed breast cancer patients by Keitel, Zevon, Rounds, Petrelli, and Karakousis (1990), spouses distress levels declined over time and those whose distress remained elevated were more likely to be married to patients with relatively higher levels of physical symptoms. Similarly, a study by Omne-Ponten, Holmberg, Bergstrom, Sjoden, and Burns (1993), comparing the levels of adjustment among husbands of patients who had undergone either breast conserving surgery or mastectomy, showed that 48% of couples continued to experience emotional distress up to 13 months postsurgical treatment. This rate was reported to be similar to that reported in patients themselves. That distress levels dissipate over time or reach a plateau is inconclusive. In fact, one study suggested that depression may even worsen for both partners (Goldberg, Wool, Glicksman, & Tull, 1984). This implies that a sizeable proportion of couples continue to experience significant distress even after the immediate shock and crisis of diagnosis and treatment have elapsed (Baider, 1998; Sabo, 1986; Zahlis & Shands, 1991). In light of the findings supporting that chronic illness impacts the couples system and not just the patient, it follows that coping and treatment strategies should be reformulated as interpersonal processes. Coping with chronic illness, as an interpersonal process, has been addressed by a limited number of studies (Shields, Travis, & Rousseau, 2000), despite documented evidence linking quality of marital interactions and disease outcomes. One of the earlier studies, for example, poignantly pointed out that adapting to a cancer diagnosis will be altered by the quality of a couples relationship (Hannum, Giese-Davis, Harding, & Hatfield, 1991), which will in turn impact coping mechanisms employed and disease outcomes (Shields, 2000). In another study of a patient population with congestive heart failure, Coyne et al. (2001) showed that marital quality in fact predicted survival. Conversely, marital distress was repeatedly associated with disease symptomatology, negative health outcomes, and reduced immune function (Greene & Griffin, 1998; Kiecolt-Glaser, Fisher et al., 1987; Kiecolt-Glaser, Glaser, Cacioppo, MacCullum, & Snydersmith, 1997; Kiecolt-Glaser, Kennedy et al., 1988; Marcenes & Sheiham, 1996). A persons intimate relationship provides a unique type of support that if absent or experienced aversively during chronic illness will lead to a greater likelihood of mood disturbance. For example, Vinokur and Vinokur-Kaplan (1990) found that receiving negative emotional support or undermining responses from

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their husbands was related to breast cancer survivors depressive symptoms. In fact, the attachment relationship has been found to be of such potency that if troubled, the ensuing distress cannot be simply overcome by additional social support (Pistrang, Barker, & Rutter, 1997). These findings parallel those from the noncancer literature which maintain that a husbands withdrawal is experienced aversively by his wife (Gottman, 1994). Several lines of inquiry have closely examined the impact of specific behavioral interactions on coping. For example, in a study examining husbands reactions to their partners illness, Sabo, Brown, and Smith (1986) found that while their wives were undergoing mastectomies, men tended to adopt a protectors role while simultaneously avoiding any open expression of feeling. Such stereotypic male behavior was experienced aversively by their spouses and was also perceived as insensitive and rejecting (Sabo et al., 1986). This pattern was found elsewhere within the cancer literature in which avoidance of open discussion about the cancer patients experience was related to greater distress (Spiegel, Bloom, & Gultheil, 1983; Vess, Moreland, Schwebel, & Kraut, 1988). The psychological distress ensuing from avoidance of processing the cancer experience also has physiological substrates which have been shown to impact the immune system. In an attempt to account for these findings, attachment theory is advanced as the most cogent interpersonal framework from which the coping process may be understood, in addition to providing a context for ameliorating psychological adjustment including disease-related variables. The attachment model of adult intimacy views a relationship between couples in terms of a bond with an irreplaceable other. This psychological tie is a function of four interrelated elements; emotional, cognitive, behavioral, and physiological processes that interact to optimize survival. An individuals response to any real or perceived separation from or loss of an attachment figure (Bowlby, 1982), particularly in the face of threat, has been shown to instigate a predictable series of responses designed to reinstill the bond and to facilitate an adaptive response to environmental demands (Bowlby, 1988). Proximity-seeking behavior in the face of physical/psychological stress or threat has clear survival value in that comfort and security are obtained from the attachment figure thereby restoring the individuals psychological/physical homeostatic deviations to optimal states which will in turn enhance adaptation to or coping with the presenting stressor. Of particular relevance to attachment theory are working models (Bowlby, 1973; Bowlby, 1980). These models are used to describe internal representations that individuals develop both of the self and of significant people in relation to the self. Working models are relevant in this discussion for they determine ones attachment style which may be conceptualized as ones behavioral response to both perceived and actual distress, in addition to the separation from and reunion to an attachment figure. The most recent and reliably identified model of attachment styles found in the adult attachment literature is one of four attachment styles: secure, preoccupied, dismissive, and fearful avoidant (Bartholomew & Horowitz, 1991; Johnson, Makinen, & Millikin, 2001). These ways of relating may be also

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conceived of in terms of long-standing patterns of expectations or strategies that have developed as a result of past relationships (Simpson, Rholes, & Nelligan, 1992). Attachment styles, concretized as two working models, one of self-worth juxtaposed against one of the accessibility and responsiveness of others in times of need, function as inner filters through which individuals organize their experiences and behave to meet situational demands. Attachment styles, therefore, can be conceptualized as mediating coping mechanisms which are mobilized in the face of stressful situations. Therefore, to the extent that distress is experienced and handled behaviorally, the individual will successfully adapt to the changing demands of a chronic condition. Following this line of argument, secure attachment has been found to function more like an inner resource (Mikulincer & Florian, 1998) that enables the individual to cope more adaptively in the face of stress, thereby optimizing adaptation. Interpersonally, individuals with secure attachment styles are able to seek and utilize support provided from significant others who through past experience have demonstrated their accessibility and responsiveness particularly in times of distress (Bartholomew & Horowitz, 1991; Shaver & Hazen, 1993). An individual with a secure attachment style typically engages in information search, possesses high tolerance for unpredictability, disorder, and ambiguity, is reluctant to endorse rigid beliefs, is able to integrate new pieces of information into memory and appraisal systems, and able to revise schemata. Conversely, individuals with insecure attachment styles (preoccupied, fearful, and dismissive) tend to be characterized by unstable and less than adequate strategies of affect regulation (Bowlby, 1973; Shaver & Hazen, 1993). The relative lack of inner resources, inherent in those individuals with insecure attachment styles, predisposes them toward exaggerating the magnitude of threat and uncontrollability imposed by a stressful event. In comparison to a securely attached individual and in the face of the same stressor, the insecurely attached counterpart is more likely to experience heightened distress even after the source of stress has dissipated (Mikulincer & Florian, 1998). Attachment theory, in addition to providing an account of interpersonal behaviors that are likely to be activated in the face of a crisis such as illness, is fundamentally a theory of affect regulation. An attachment style, therefore, is not a trait that manifests across situations, but rather is a dynamic state continually in flux with stress and other anxiety variables such as serious illness. For example, theorists concur that, in the face of crisis, those individuals with dismissive attachment styles tend to rely heavily on dissociative strategies to reduce their experienced or felt distress. Dissociative strategies, while they may regulate distress in the short term are likely to prove maladaptive over the long run. Pennebaker and Epstein (1983), in their research on the effects of repressive coping and health, echo similar conclusions. Specifically, individuals who cope via repression, in comparison to emotional disclosure tend to manifest immune down-regulation. In summary, the current literature lends support to the authors position that diagnosis and treatment of chronic illness unfolds in the context of an interpersonal

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context that affects and is affected by the disease process in a dynamic and reciprocal fashion. As such, coping and adjustment need to be reformulated to account for a previously neglected interpersonal dimension. Attachment theory offers the most compelling framework from which to understand interpersonal behaviors that serve to modulate coping and adjustment of a couple dealing with chronic illness. Emotionally Focused Therapy is a couples-based approach that is taught and used in many different cultures throughout the world (Johnson, 2004). Further, EFT is an empirically validated approach that offers the clinician a clear road map that can be applied when working with couples facing any type of chronic illnesses. COUPLES AND CHRONIC ILLNESS: AN ATTACHMENT PERSPECTIVE & EMOTIONALLY FOCUSED THERAPY INTERVENTIONS In this section two vignettes will be presented to illustrate relationship distress and chronic illness in terms of the attachment theory and the emergence of negative cycles. These negative cycles prevent the couples from comforting each other at a time when they need each other the most. Both couples respond to EFT interventions and are able shift to a more secure relationship bond despite chronic illness. EFT is a three-stage process that focuses on the power of emotion and emotional communication to build resilience in the face of traumas such as illness. The three stages of EFT are further delineated into nine steps that guide the therapists interventions (Johnson, 2004). The first stage is about identifying and helping the couple to understand their cycle. The defensive strategies that each partner uses to cope are validated and normalized, and the cycle is framed as the enemy. The therapist touches on the primary emotions underlying the defensive positions, and helps the couple to see that this cycle is about more than meets the eye. Couples facing chronic illness will present with any type of cycle, including pursue-withdraw, withdraw-withdraw, or multi-move cycles. The cycle may have escalated after the onset of the illness, but may have been established in the years prior to diagnosis. The stress of chronic illness can change a tolerable negative interactive pattern into an intolerable one. On the other hand, the nature of a particular chronic illness itself may cause negative cycles to appear when a previously secure couple can not turn to their habitual way of dealing with stress. What ever the case, the EFT therapist proceeds through the identified three stages of therapy: de-escalation and identifying negative cycles; changing interactional positions and building positive cycles; consolidation and integration. Depending on their stage of life and on the type of chronic illness the family encounters, family life can be disrupted and strained by numerous and varied factors (for example, financial or time pressures, child care needs, etc.). Difficult, painful, and vulnerable emotions such as loss, fear, shame and guilt, sadness and anger can arise for both partners. Depending on the way each one copes with such

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feelings, negative interactive cycles can be set up between partners. These negative interactive cycles in couples are built of defensive reactions. We all tend to have particular ways of responding when we experience threat. Some of us may become tearful or irritable, while others may become withdrawn, keeping our feelings to ourselves. A partner might fear, for example, his/her worries are too threatening or too onerous to share with the partner. Negative interactive cycles are the product of the interaction between the partners way of coping with threat. For example, one partner may become anxious, with an accelerated need for information and soothing just as the other becomes withdrawn and unavailable. The withdrawal of one intensifies the anxiety of the other, which further primes the withdrawal of the first. The resulting cycle of defensive emotion and behavior adds to the distress already present due to the chronic illness, and robs couples of their most powerful antidote: comfort and connection from each other. In the first vignette, a couple comes to therapy when an entrenched negative cycle is exacerbated as an attachment injury occurs after a cancer diagnosis. In the second vignette a previously secure couple struggle to deal with an illnessproduced negative cycle that is beginning to envelop their relationship. Vignette #1 Doris was 61 years old and had been married for 43 years when she was diagnosed with breast cancer and underwent surgery and chemotherapy. For Doris, the worst part of this difficult time was when her husband declined to attend an important meeting scheduled by her physician who told her it was important for him to attend. When she insisted, telling Henry, her husband, that the physician wanted him there, Henry told her he was sorry, but he had an important business commitment out of town and would not be able to go. Three years following this event, Doris told Henry she wanted to leave him. Henry, who had been the withdrawn partner in this relationship for most of the 43 years went into fairly vigorous pursuit and persuaded Doris to come with him for therapy. In therapy the couples longstanding withdraw/withdraw cycle was quickly identified. Difficulty communicating went back to before the couple married. Henry was a man of few words and Doris was quiet and shy, with little self-confidence. The couple had three children in rapid succession and Doris soon found herself spending her days in their isolated home outside a small village, with only her children for company. Henry worked extremely long hours in his own business, and said very little to his wife when he returned home. Doris noticed that the only person he discussed anything with was his older brother. She concluded that he found her boring. Over the years, Doris developed close friendships in the village. She and Henry would eat together at the end of the day, but otherwise spent very little time together. It seemed that the only time they were able to connect was when they discussed their children. Over the years, Doris sadly came to the conclusion that her husband did not value her very much, and Henry certainly never told her any-

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thing to the contrary. He did try in many different ways to let her know he cared for her, for example, for her 50th birthday he bought her a sports car. However Doris never felt comfortable driving it as she felt it did not suit her personality, and she assumed that he had really bought it for himself. It also became apparent that the couples cycle had changed as Doris began to regain her strength following her chemotherapy treatment. She became openly angry with Henry and on the infrequent occasions that he did speak to her, she responded with great anger and sarcasm. This had the effect of further shutting Henry down, to the extent that he even began refusing to join her on their daily walks by the lake. Their already minimal contact dwindled to almost nothing. As Doris confided to the therapist and her husband, it is easier to be lonely when I am on my own, than when I am at home with a man who is meant to be my life companion. As the couple worked in therapy, it was clear that Doris was not only extremely angry with her husband, but also clinically depressed. She felt that she had missed out in her life, and had spent her life with someone who did not value her. Although at one level she had thought this for most of her life with Henry, when he refused to support her by attending a pivotal medical appointment, this seemed to take his lack of feeling for her to a new level. She felt she could no longer bear to live with a man who cared so little for her. The presenting cycle was articulated as: Henry, afraid anything he might say would rock the boat, stayed withdrawn, quiet, and avoided his wife. His avoidance of her served to exacerbate her anger, reminding her that she was not precious to him. She then snapped and yelled at him, and her anger further primed his withdrawal. Week after week Henry remained withdrawn in our sessions, afraid that anything he might say would exacerbate her anger at him. His silence was framed as more toxic than anything he could ever say to Doris. Eventually, Henry began to take risks in therapy and to share his fear of her anger. He worried, as he heard his wife dismiss their marriage as a lost opportunity, that the crimes he had committed were completely unforgivable, and he would lose her. He told her how important she was to him, that he had always been afraid that if he opened up and showed her who he was on the inside, she would find there was nothing there. He saw his wife as a socially skilled and loveable woman, and felt he had so little to offer her. These revelations amazed his wife who for decades had imagined that he had only scorn for her. She began gradually to reappraise her partner, and as her picture of him changed, she also began to disclose more about herself. She told the therapist and her husband about the shame she had always felt following years of sexual abuse by her uncle, with whom she lived as a child in Germany. She had never disclosed this to anyone before, and Henry reacted with great compassion for her. The couple remained in therapy for almost two years. The process was slow, for their cycle had been entrenched for so many years. Henry and Doris told each other details of their lives that they had never even imagined. They accessed immense sadness that so many years were spent not knowing each other. Doris, however, still

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did not soften toward her husband. She continued to have angry outbursts and ignore his attempts to be close to her. As her anger was explored it always came back to the incident wherein she had needed his support so badly, indeed the cancer physician had told her that her husband should attend the appointment, but he refused to place her need ahead of his business. I learned that day that even though my life is in danger, I could not count on you to see me as important. The final stage of therapy involved resolution of this event, which was framed as an attachment injury. Attachment injury is a term used in EFT to describe a specific incident or event that is experienced as a betrayal or abandonment by one of the partners. This negative experience has a unique and long-term impact on the injured partner and on the couple relationship (Johnson, Makinen, & Millikin, 2001). In this case, the resolution of the attachment injury involved Henry listening intently as his wife made the links between feeling on her own when she went to the medical appointment and feeling alone with her problem with her uncle as a child. Nobody cared. There was nobody there to care, she said tearfully. It felt just the same, like I dont matter, I dont count. Henry reassured her that he finally understood the impact of this event, and told her how sorry he was. He told her he knew he had let her down, that he was frightened by the cancer and that in addition he did not realize that it would help her to have him there. I thought I had nothing to offer, so I left town, he said ruefully. This led the couple into discussing their fears around her cancer and the dangers of discovering each other only to risk losing this precious bond. When Doris and Henry left therapy they had crossed the miles and the years that had kept them apart and lonely. In this case example, an already entrenched cycle became exacerbated severely as a result of an attachment injury during the early days of illness. Vignette #2 The authors suggest that the attachment framework and EFT interventions can be universally applied across all types of chronic illness. Johnson writes, Health in systemic terms is about flexibility and the ability to adapt inner models of the world and behavioral responses to new contexts . . . Change happens in the head and in the heart, but also in interactions (Johnson & Whiffen, 2003, p. 12). In this second vignette, a couple is apparently unable to call upon their secure attachment behaviors as they face the suddenly acquired disability of aphasia. Although not well known or understood even by professionals this disability affects over a million families in North America. Aphasia creates a context that challenges our model of self and other and puts at risk even the most secure relationships. The very nature of this chronic disability also challenges the therapists own flexibility, ability to develop a working therapeutic alliance, and ability to continue through the stages of therapy. Aphasia is the loss of the ability to process language due to damage to the speech center located in the left side of the brain. Adults who acquire aphasia are limited

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in their ability to participate in relationships due to difficulties in one or more of the following areas: talking, understanding speech, reading, writing, or numbers. Unlike dementia, individuals living with aphasia are aware of their loss of language and indeed their thoughts are unaffected. As one client repeated over and over again: I know, I know, I know, but, but, words . . . ugh! When the therapist attends to his gestures, it is clear that this client is communicating that he knows what he wants to say, the words are in his head, but when he goes to speak he cannot retrieve them. The therapist can check out if this is the correct message by a number of techniques such as, slowing down speech, providing the words for the client, writing key words on paper and having the client indicate yes or no as to whether or not the therapist is on track. Although a variety of neurological conditions may cause aphasia, it is most commonly the result of a stroke. Consequently, many people coping with aphasia are also adjusting to mild to severe right-sided physical deficits. Couples living with severe physical losses post-stroke often state that, while the physical loss is devastating, the changes in the ability to talk with each other is more distressing. One couple referred to the experience as a life sentence rather than a life saved. Elsewhere, it has been described as identity theft (Shadden, 2005). In this new context, feelings of vulnerability and attachment behaviors are heightened, concurrent with being deprived of language, the main vehicle for seeking out others for connection. Rick and Judy, ages 67 and 65, were seen for ten sessions of EFT, five months after Rick had been discharged home following a stroke resulting in severe global aphasia. This was the second marriage for both and they had recently celebrated their 34th wedding anniversary. They described a happy and secure relationship prior to the stroke. They had frequent contact with their two adult children and enjoyed the accomplishments of their five grandchildren. At the time of the stroke, Rick and Judy were enjoying a physically active retirement, traveling and socializing regularly with friends. Rick had bypass surgery ten years previously, and they felt particularly fortunate to be able to continue this active lifestyle together. EFT was provided to Rick and Judy by integrating communication strategies developed by speech language therapists into the therapy sessions. Collectively these strategies are referred to as supported conversation for adults with aphasia or SCA (Kagan, 1998). SCA can be integrated in couple counseling by having a speech therapist attend the session as a co-therapist (Stiell & Gailey, 1995). In this case the EFT therapist was experienced in using SCA, and used the speech therapist only as a consultant outside of sessions. EFT, with its interventions that focus on the here and now of the couples experience, lends itself well to supported conversation strategies. Communication difficulties result in extremely high levels of frustration, anger and, left unsupported, may lead to violence. With this couple, therapy played an important role in helping them recognize the secondary and primary emotions contributing to their negative cycle. Prior to Ricks discharge home from hospital, Judy was extremely anxious and felt she would be unable to cope. Rick had

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only mild physical deficits and was discharged after a very brief hospitalization. However, his global aphasia meant that he had difficulty in both expressive and receptive abilities. Judy was at a loss as to how to communicate with him just to get through the day. Ricks thoughts were okay, he knew what he wanted to say, but when he went to say something the words that came out were, Tee, tee, tee . . . He became increasingly frustrated and angry when others, but especially when Judy, did not understand him and on these occasions produced, much to Judys embarrassment, the word Fuck. The harder Rick and Judy tried and then failed to communicate, the greater their angry outbursts and distress. Judy was torn between wanting to have her husband home and being in her words, scared out of her mind, because it seemed like she was living with a stranger. Judy was constantly watching for symptoms of another stroke, had difficulty sleeping and was tearful throughout the day, in addition to dealing with painful shingles. At the time the couple entered therapy they had stopped seeing friends and family get-togethers were described as tense. More distressing, they were feeling isolated from each other even though physically together all the time. Judys depression score was close to the severe range. It was clear that a withdrawwithdraw cycle was beginning to dominate their interactions. Given the tools they had, this was perhaps the best way to cope with their new and increasingly stressful situation. Rick would try to say something and soon gave up in frustration because Judy did not understand. He would move to another area of the house, sit by himself and put the newspaper in front of his face. Judy after many failed attempts at trying on her own to guess what Rick was saying or discussing any of the important issues on their plate, had moved to her own withdrawal stance. In her words, I just give up. I am exhausted. Its easier than the frustration of not getting it or the risk of angry outbursts. And I dont want to make him feel stupid when I cant get it. Although she felt desperately alone, Judy also believed it would be a betrayal to talk about her own painful experience to either the children or friends. She needed to be the strong one now. Underlying the feeling of rejection and disconnection between Rick and Judy and adding fuel to the negative cycle was the question of competence. Am I crazy? Am I loveable? Can I depend on this person to respond to me? The process of using SCA to help develop an alliance with both partners and delineating the negative cycle helped to dispel questions about competence. The process of validating each persons experience and creating for the first time since the stroke, a place where they felt heard, or more accurately, being heard more often, was a great relief. The process itself reassured both partners and conflicted with their previous experience of apparent incompetence. This change event opened the door to stage two of EFT. Even though the disability of aphasia remained, it no longer was a seemingly insurmountable threat to their relationship. The following transcript is from a session in stage two of EFT. Judy no longer feels she must protect Rick and feels safe to talk about her own experience, even the conflicting feelings she had when he came home. Listening to Judy provides the

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opportunity for Rick to be there for Judy, reinforcing his restored sense of self and role as the man she can count on. The transcript highlights how the therapist can attend to both supporting conversation and helping the couple create a new dance.
Judy: This week I was able to talk to Rick and tell him what it was like in that first month. He has come a long way since then, but it was pretty bad at this time last year, the way he was really down on himself, not being able to do things. Rick: Oh, tee, tee, tee, tee. (Looking at Judy and gesturing by throwing up his hands as in, I didnt know.) Therapist: Rick, let me check this out. Are you saying, in early days . . . forgot . . . what it was like? (Therapist speaking slowly, writing key words on paper to help Rick track the conversation) Rick: (As he speaks also motions with his head yes) Tee, tee, tee. Judy: It was just horrible then. I was afraid of you and didnt know if I could handle it. I had to learn about your medication and worried about another stroke. You were angry and irritable. When I looked into your eyes, it was like it was not you. I didnt know you. Rick: Tee. (Laughs nervously and throws up his hands in a gesture indicating helplessness.) Therapist: (Checks out that Rick has received what Judy said by writing on paper: before, Judy, afraid, you. Shows written words to Rick and slowly reads out loud each word, points first to Judy and then to Rick.) Rick: (Silent pause; looks at the written words pointing to them, reaches forward and touches Judys arm) Tee, tee. Therapist: So now Judy things are better? (Gestures with a thumb up.) Judy: Yes, like we had a fight this morning, and I just got the paper and wrote down these words and it solved everything. (Judy takes the paper from her purse and shows the therapist.) Usually this kind of incident would mean that the rest of the day is ruined. Rick: Tee, tee, tee. (Laughing and motioning yes with his head.) Judy: It is more like the old days, like I got the old Rick back. Therapist: (Heightening, repeating) The old days? What parts of the old Rick is back? Judy: I noticed his eyes, except when he is tired, they are Ricks eyes, looking at me, yes looking at me, focusing and understanding. My feelings are, like I am with the old Rick. Therapist: (Repeating slowly, making eye contact with Rick.) Somehow, you can look in his eyes . . . and . . . now see the old Rick . . . he is back! Rick: Yes, tee, tee. (Looking at Judy, laughing and smiling.)

Later in the session Judy refers to a conversation she had with a friend, telling the friend that she has the old bossy Rick back.
Therapist: (Slowly repeating to Judy in her own words.) He is his old bossy self, thats the guy you missed. The boss is back. Judy: (This time not the therapist, but Judy herself takes the pencil and writes BOSSY and as she writes, shows it to Rick.) I told our friend Alice that I have the old bossy Rick back.

Couples and Chronic Illness Therapist: The old boss? The boss is back! Judy: (Affectionately looking at Rick.) If thats getting you back, thats my old bossy guy. Therapist: You missed the boss. (To Rick who is laughing) You have become your old bossy self. Rick, the boss is back. Rick: Tee, tee, tee. (Sticking his chest out and nodding his head indicating yes.)

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As competence was gradually revealed to both Rick and Judy through the integration of EFT and SCA, Rick became less frustrated, angry outbursts declined, and he was more motivated to communicate with Judy. Judys own confidence in facilitating conversation grew with her experience in the supportive therapeutic environment. Not getting the message in or out, no longer created a crisis and they learned to laugh or cry at failed efforts and take time out when frustration levels went too high. In this safe environment they were able to use supportive conversation to share underlying emotions. The question of placement outside the home was no longer an issue as they began to enjoy their time together. No longer feeling a sense of embarrassment as they now stood together, they also began to socialize with close friends. Despite the devastating impact of chronic aphasia and the challenging context created by the very nature of this disability, it was possible to help Rick and Judy to move through the stages of therapy and reestablish their relationship.

SUMMARY Health and adjustment following chronic illness is a serious and growing concern for health care providers. This article proposes that coping and treatment strategies should include interpersonal processes as pivotal to rehabilitation. In our efforts to provide rehabilitation programs and long-term support to the growing number of people affected by chronic illness, this dimension warrants further exploration. While chronic illness does not discriminate across cultures, there is a need to validate our interpersonal intervention focus in more diverse settings. A review of the current literature provides substantive evidence that reciprocal dynamics exist between the onset of any type of chronic illness and adjustment in the context of a couples relationship. Long after the initial shock of diagnosis and treatment, significant distress may continue and can be understood in terms of attachment theory. The two vignettes presented above illustrate how relationship distress can evolve in the context of chronic illness. In the real world chronic illness may affect a relationship that was already in distress and bring it to an unbearable level, or it may threaten a previously secure relationship. EFT provides an opportunity for health care providers to respectively enter into the personal world of relationships and illness and work to alleviate distress. The relationship can then become a valuable resource for both partners as they face chronic illness together.

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