- 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’.
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).
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 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.
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).
- 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.
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 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.