3.1. Case studies of the couples
In the following, the case studies of the concordant couples are described. For each couple the psychodynamics over the course of the treatment and relations to demographic and clinical variables and symptom improvements are worked out.
Case study of Couple 1: At admission of therapy we detected a collusion between the female and male patient. The female patient largely took care of the male patient. She also took the lead and organized their social life. During clinical visits, she often spoke for him. Furthermore, she often cut him short during conversations or commented on his ideas as ridiculous. The dominant affects of the male patient were insecurity and subliminal anger. Due to his insecure self-perception he handed over the responsibility to his partner, simultaneously he felt worthless, insufficient and dependent of his partner, which made him angry. The female patient enjoyed to be needed from her partner. She felt self-confident, when she could support him. However, she felt burdened because she had to organize everything. He seemed socially dependent on her, which seemed to increase her self-esteem. The psychodynamic characterization revealed a characteristic pattern: the male patient seemed to have the position of inferiority, neediness, submission, deficiency and passivity and the female patient the position of caregiving, activity, control, strength and superiority.
Table 4 shows the demographic and clinical variables as well as the outcome changes for Couple 1. Both patients were in early adulthood and three years together. Both completed a vocational training, but had no stable housing. They used multiple-drugs, had no comorbid disorder and were Hepatitis B and C negative. According to the GSI the female patient didn´t change reliable or clinically significant, but she made substantial improvements in Somatization, Paranoid Ideation and Psychoticism [29]. For the male patient we couldn´t calculate the RCI due to data loss. Follow-up data showed that both partners received subsequent therapy after treatment termination at the ward. One year after treatment termination Couple 1 was still together and raised a family with two children.
Table 4. Demographic and clinical variables and outcome change for Couple 1.
|
1W
|
1M
|
Demographic and clinical variables
|
|
|
Age (years)
|
29
|
27
|
Length of partnership (years)
|
3
|
3
|
Education
|
+
|
+
|
Housing
|
neg.
|
neg.
|
Substance use
|
B, C, H
|
B, H, THC, Sirdalud
|
Comorbidity
|
none
|
none
|
Hepatitis B
|
neg.
|
neg.
|
Hepatitis C
|
neg.
|
neg.
|
Treatment length (days)
|
117
|
113
|
Outcome variables
|
|
|
|
|
BSI
|
Mt1
|
Mt2
|
Mt1
|
Mt2
|
GSI
|
1.40
|
1.00
|
1.30
|
n.a.
|
Somatization
|
1.10
|
0.10
|
1.40
|
n.a.
|
Obsession-Compulsion
|
1.00
|
0.50
|
1.50
|
n.a.
|
Interpersonal Sensitivity
|
0.50
|
0.25
|
0.50
|
n.a.
|
Depression
|
1.00
|
0.50
|
0.70
|
n.a.
|
Hostility
|
0.30
|
0.20
|
1.00
|
n.a.
|
Phobic Anxiety
|
0.80
|
0.80
|
1.70
|
n.a.
|
Paranoid Ideation
|
0.80
|
0.20
|
1.60
|
n.a.
|
Psychoticism
|
0.80
|
0.00
|
1.20
|
n.a.
|
Seeking subsequent therapy
|
yes
|
yes
|
|
|
|
|
|
|
|
|
Note. W = woman, M = man, Education: + = completed a vocational training, - = completed no vocational training, Housing: neg. = no fixed abode, pos. = fixed abode, Substance use: B = Benzodiazepine, C = Cocain, H = Heroin, THC = Cannabis, Mt1 = mean score at admission of therapy, Mt1 = mean score at termination of therapy, GSI = Global Severity Index, n.a. = not available.
Case study of Couple 2: The couple was very dissimilar. She was the driving force for the treatment, and he was rather passive. She was dependent on his love, tolerated his rude behavior and couldn´t tell him her opinion. He took advantage of her love and degraded her when she revolted. He fell into contempt and she was submissive. The dominant affects of the male patient were aggression and contempt, whereas for the female patient it was fear of loss. Primarily, she was emotionally dependent on him, whereas he was indifferent, exploitative and self-contained. The psychodynamic characterization revealed a pattern of collusion. The female patient fulfilled the dependent, submissive and inferior part, the male the independent, controlling and superior part.
Table 5 shows the demographic and clinical variables as well as the outcome changes for Couple 2. The couple was in early adulthood and two years together. Both partners didn´t complete a vocational training and had no stable housing. They had a child, but no custody for it. Both used multiple-drugs, had a comorbid personality disorder and were Hepatitis B positive and Hepatitis C negative. The GSI of both partners was in the subclinical range at admission and termination of therapy. For the female patient the GSI didn´t change reliable [29], but tended to deteriorate in Obsession-Compulsion, Interpersonal Sensitivity, Phobic Anxiety and Paranoid Ideation. The GSI of the male patient also didn´t change reliable [29], no substantial changes were detected in all scales of the BSI. Follow-up data showed, that both partners received subsequent therapy after treatment termination at the ward. The couple got engaged after leaving the inpatient therapy.
Table 5. Demographic and clinical variables and outcome change for Couple 2.
|
2W
|
2M
|
Demographic and clinical variables
|
|
|
Age (years)
|
23
|
35
|
Length of partnership (years)
|
2
|
2
|
Education
|
-
|
-
|
Housing
|
neg.
|
neg.
|
Substance use
|
C, H
|
A, C, H
|
Comorbidity
|
PD
|
PD
|
Hepatitis B
|
pos.
|
pos.
|
Hepatitis C
|
neg.
|
neg.
|
Treatment length (days)
|
94
|
93
|
Outcome variables
|
|
|
|
|
BSI
|
Mt1
|
Mt2
|
Mt1
|
Mt2
|
GSI
|
0.15
|
0.55
|
0.26
|
0.17
|
Somatization
|
0.29
|
0.50
|
0.14
|
0.29
|
Obsession-Compulsion
|
0.0
|
0.50
|
0.33
|
0.00
|
Interpersonal Sensitivity
|
0.0
|
1.25
|
0.50
|
0.25
|
Depression
|
0.00
|
0.33
|
0.17
|
0.00
|
Hostility
|
0.00
|
0.00
|
0.00
|
0.00
|
Phobic Anxiety
|
0.00
|
0.60
|
0.20
|
0.40
|
Paranoid Ideation
|
0.20
|
0.80
|
0.60
|
0.40
|
Psychoticism
|
0.00
|
0.40
|
0.20
|
0.00
|
Seeking subsequent therapy
|
yes
|
yes
|
|
|
|
|
|
|
|
|
Note. W = woman, M = man, Education: + = completed a vocational training, - = completed no vocational training, Housing: neg. = no fixed abode, pos. = fixed abode, Substance use: C = Cocaine, H = Heroin, Mt1 = mean score at admission of therapy, Mt1 = mean score at termination of therapy, PD = personality disorder, GSI = Global Severity Index, n.a. = not available.
Case study of Couple 3: In the therapy process it became obvious that the female patient took care of both partners. 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 both partners. He was highly dependent on her, whereas he was the main motivating factor behind abstinence and treatment motivation. The psychodynamic characterization revealed a role switch between care and neediness as well as between control and submission.
Table 6 shows the demographic and clinical variables as well as the outcome changes for Couple 3. The couple was middle-aged, three years together and had no stable housing. Both used multiple drugs, had a comorbid personality disorder and were Hepatitis C negative. In contrast to the female patient the male patient completed no vocational training and was Hepatitis positive. The GSI of the female patient improved clinically significant with substantial effects for all subdomains of BSI except for Paranoid Ideation [29]. The GSI of the male patient didn´t change reliable or clinically significant [29], but he improved in Obsession-Compulsion and Interpersonal Sensitivity. Follow-up data showed, that both partners received subsequent therapy after treatment termination at the ward. In addition the data showed that the couple separated after being discharged from the ward. Both partners died, the male was found dead and the female died by suicide.
Table 6. Demographic and clinical variables and outcome change for Couple 3.
|
3W
|
3M
|
Demographic and clinical variables
|
|
|
Age (years)
|
40
|
35
|
Length of partnership (years)
|
3
|
3
|
Education
|
+
|
-
|
Housing
|
neg.
|
neg.
|
Substance use
|
A, C
|
A, C, H
|
Comorbidity
|
PD
|
PD
|
Hepatitis B
|
neg.
|
pos.
|
Hepatitis C
|
neg.
|
neg.
|
Treatment length (days)
|
235
|
199
|
Outcome variables
|
|
|
|
|
BSI
|
Mt1
|
Mt2
|
Mt1
|
Mt2
|
GSI
|
0.85
|
0.11
|
0.81
|
0.47
|
Somatization
|
0.57
|
0.0
|
0.57
|
0.29
|
Obsession-Compulsion
|
1.17
|
0.17
|
1.17
|
0.17
|
Interpersonal Sensitivity
|
1.00
|
0.00
|
1.00
|
0.25
|
Depression
|
1.17
|
0.17
|
0.50
|
0.00
|
Hostility
|
0.60
|
0.00
|
1.00
|
1.00
|
Phobic Anxiety
|
1.50
|
0.00
|
0.80
|
0.60
|
Paranoid Ideation
|
0.40
|
0.00
|
1.00
|
0.60
|
Psychoticism
|
0.80
|
0.00
|
0.80
|
0.40
|
Seeking subsequent therapy
|
no
|
no
|
|
|
|
|
|
|
|
|
Note. W = woman, M = man, Education: + = completed a vocational training, - = completed no vocational training, Housing: neg. = no fixed abode, pos. = fixed abode, Substance use: C = Cocaine, A = Alcohol, H = Heroin, A = Alcohol, Mt1 = mean score at admission of therapy, Mt1 = mean score at termination of therapy, PD = personality disorder, GSI = Global Severity Index.
Couple 4: At the beginning of therapy a collusion between the female and male patient was apparent. The couple subdivided their roles, the female behaved like a caregiver, the male was dependent of her care. 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 euphemize or even repudiate the other’s negative aspects. The dominant affects were subliminal anger and fear of loss in both partners. She felt good when she could support him and this bolstered her self-esteem. He was dependent on her because she organized everything for him, and he stayed rather passive in the interaction. Consequently, the psychodynamic characterization revealed a repetitive pattern between care and neediness as well as between activity and passivity, whereas the female patient primarily filled a role of caregiving and the male patient the role of neediness and consumption.
Table 7 shows the demographic and clinical variables as well as the outcome changes for Couple 4. The couple was in early adulthood and were eight months together. The female patient completed a vocational training, had a stable housing, used multiple drugs, but had no comorbid disorder and was Hepatitis B and C negative. In contrast, the male patient completed no vocational training, had no stable housing, was Heroin dependant with a comorbid Attention Deficit Hyperactivity Disorder and was Hepatitis C positive. The GSI of the female patient did not change reliable or clinically significant [29]. She tended to deteriorate in GSI, Obsession-Compulsion, Interpersonal Sensitivity, Hostility, Paranoid Ideation and Psychoticism. The GSI of the male patient also didn´t change reliable or clinically significant [29], but he tended to improve in Interpersonal Sensitivity, Phobic Anxiety and Psychoticism. Follow-up data showed, that both partners received subsequent therapy, but separated after treatment termination at the ward.
Table 7. Demographic and clinical variables and outcome change for Couple 4.
|
3W
|
3M
|
Demographic and clinical variables
|
|
|
Age (years)
|
25
|
26
|
Length of partnership (months)
|
8
|
8
|
Education
|
+
|
-
|
Housing
|
pos.
|
neg.
|
Substance use
|
C, H, THC
|
H
|
Comorbidity
|
none
|
ADHD
|
Hepatitis B
|
neg.
|
pos.
|
Hepatitis C
|
neg.
|
neg.
|
Treatment length (days)
|
86
|
100
|
Outcome variables
|
|
|
|
|
BSI
|
Mt1
|
Mt2
|
Mt1
|
Mt2
|
GSI
|
2.04
|
2.53
|
2.25
|
2.06
|
Somatization
|
2.43
|
2.14
|
2.86
|
2.71
|
Obsession-Compulsion
|
2.17
|
2.83
|
1.33
|
1.83
|
Interpersonal Sensitivity
|
1.25
|
3.25
|
3.00
|
1.75
|
Depression
|
2.33
|
2.33
|
2.17
|
2.00
|
Hostility
|
2.00
|
3.60
|
2.40
|
2.00
|
Phobic Anxiety
|
1.80
|
1.40
|
1.80
|
1.00
|
Paranoid Ideation
|
1.20
|
2.60
|
1.80
|
1.40
|
Psychoticism
|
2.40
|
2.00
|
2.20
|
1.60
|
Seeking subsequent therapy
|
yes
|
yes
|
|
|
|
|
|
|
|
|
Note. W = woman, M = man, Education: + = completed a vocational training, - = completed no vocational training, Housing: neg. = no fixed abode, pos. = fixed abode, Substance use: C = Cocaine, H = Heroin, THC = Cannabis, ADHD = Attention Deficit Hyperactivity Disorder, Mt1 = mean score at admission of therapy, Mt1 = mean score at termination of therapy, PD = personality disorder, GSI = Global Severity Index.
Couple 5: The couple behaved mostly harmonic and adjusted to each other. For example, they often shared the same topics. If one partner focused on medication, so did the other. The same could be said about their mood. On the one hand conflicts seemed to be repudiated, on the other hand, the couple sometimes entrapped in massive conflicts with mental and physical abuse. Here, the male partner was the submissive and the female the overt aggressive part. The interaction was conceptualized as an offender-victim relationship. The dominant affects of him were fear of loss, whereas she felt fury and guilt. They resolved these conflicts by caring of each other. Consequently, the psychodynamic characterization revealed a repetitive pattern between care and neediness and between control and submission.
Table 8 shows the demographic and clinical variables as well as the outcome changes for Couple 5. The couple was in early adulthood and were three years together. Both didn´t complete a vocational training, but had a stable housing. They used multiple drugs. She had no comorbid disorder and was Hepatitis B and C negative, in contrast he had a comorbid Attention Deficit Hyperactivity Disorder and was Hepatitis B positive. For Couple 5 the BSI data are missing. Follow-up data showed, that both partners received subsequent therapy.
Table 8. Demographic and clinical variables and outcome change for Couple 5.
|
5W
|
5M
|
Demographic and clinical variables
|
|
|
Age (years)
|
25
|
22
|
Length of partnership (years)
|
3
|
3
|
Education
|
-
|
-
|
Housing
|
pos.
|
pos.
|
Substance use
|
B, C, H, O, THC,
|
A, B, H
|
Comorbidity
|
none
|
ADHD
|
Hepatitis B
|
neg.
|
pos.
|
Hepatitis C
|
neg.
|
neg.
|
Treatment length (days)
|
86
|
100
|
Outcome variables
|
|
|
|
|
BSI
|
Mt1
|
Mt2
|
Mt1
|
Mt2
|
GSI
|
n.a.
|
n.a.
|
n.a.
|
n.a.
|
Somatization
|
n.a.
|
n.a.
|
n.a.
|
n.a.
|
Obsession-Compulsion
|
n.a.
|
n.a.
|
n.a.
|
n.a.
|
Interpersonal Sensitivity
|
n.a.
|
n.a.
|
n.a.
|
n.a.
|
Depression
|
n.a.
|
n.a.
|
n.a.
|
n.a.
|
Hostility
|
n.a.
|
n.a.
|
n.a.
|
n.a.
|
Phobic Anxiety
|
n.a.
|
n.a.
|
n.a.
|
n.a.
|
Paranoid Ideation
|
n.a.
|
n.a.
|
n.a.
|
n.a.
|
Psychoticism
|
n.a.
|
n.a.
|
n.a.
|
n.a.
|
Seeking subsequent therapy
|
yes
|
yes
|
|
|
|
|
|
|
|
|
Note. W = woman, M = man, Education: + = completed a vocational training, - = completed no vocational training, Housing: neg. = no fixed abode, pos. = fixed abode, Substance use: C = Cocaine, H = Heroin, THC = Cannabis, B = Benzodiazepine, A = Alcohol, PD = Personality Disorder, Mt1 = mean score at admission of therapy, Mt1 = mean score at termination of therapy, GSI = Global Severity Index.
3.2. Symptom change
On average the patients didn´t change significantly on the BSI between pre- to post-treatment. Only the patient 3W improved reliable and clinically significant. On the level of the couples, Couple 3 seemed to benefit most with regard to symptom reduction. Table 9 presents the symptom change between pre- and post-treatment for women and men separately. None of the effects gained significance. For the men, all effect sizes were at least small in size. Large effects were found for the GSI, Interpersonal Sensitivity, Depression, Paranoid Ideation and Psychoticism. For women the effect sizes were also at least small in size, with the exception of the GSI and Obsession-Compulsion. The largest effect was found for Somatization. However, it should be noted, that for women Interpersonal Sensitivity, Hostility and Paranoid Ideation increased during inpatient therapy.
Table 9. Means, standard deviations and results of the paired sample t-test for the pre-post treatment comparisons on BSI for women and men
|
t1 t2 Post Paired differences T p Cohen's d
|
|
Gender
|
M
|
SD
|
M
|
SD
|
M
|
SE
|
|
|
|
|
GSI
|
Women
|
1.11
|
0.80
|
1.05
|
1.05
|
0.06
|
0.30
|
0.21
|
n.s.
|
0.10
|
|
|
Men
|
1.11
|
1.03
|
0.90
|
1.02
|
0.21
|
0.07
|
2.84
|
n.s.
|
1.64
|
|
Somatization
|
Women
|
1.10
|
0.95
|
0.69
|
0.99
|
0.41
|
0.25
|
1.63
|
n.s.
|
0.81
|
|
|
Men
|
1.19
|
1.46
|
1.10
|
1.40
|
0.09
|
0.13
|
0.73
|
n.s.
|
0.42
|
|
Obsession-Compulsion
|
Women
|
1.09
|
0.89
|
1.00
|
1.23
|
0.09
|
0.40
|
0.21
|
n.s.
|
0.11
|
|
|
Men
|
0.94
|
0.54
|
0.67
|
1.01
|
0.28
|
0.43
|
0.64
|
n.s.
|
0.37
|
|
Interpersonal Sensitivity
|
Women
|
0.69
|
0.55
|
1.19
|
1.48
|
-0.50
|
0.68
|
-0.73
|
n.s.
|
-0.37
|
|
|
Men
|
1.50
|
1.32
|
0.75
|
0.87
|
0.75
|
0.29
|
2.60
|
n.s.
|
1.50
|
|
Depression
|
Women
|
1.13
|
0.95
|
0.83
|
1.01
|
0.29
|
0.29
|
1.00
|
n.s.
|
0.50
|
|
|
Men
|
0.95
|
1.07
|
0.67
|
1.15
|
0.28
|
0.11
|
2.55
|
n.s.
|
1.47
|
|
Hostility
|
Women
|
0.75
|
0.85
|
1.13
|
1.67
|
-0.38
|
0.46
|
-0.82
|
n.s.
|
-0.41
|
|
|
Men
|
1.13
|
1.21
|
1.00
|
1.00
|
0.13
|
0.13
|
1.00
|
n.s.
|
0.58
|
|
Phobic anxiety
|
Women
|
1.03
|
0.80
|
0.70
|
0.58
|
0.33
|
0.44
|
0.73
|
n.s.
|
0.37
|
|
|
Men
|
0.93
|
0.81
|
0.67
|
0.31
|
0.27
|
0.29
|
0.92
|
n.s.
|
0.53
|
|
Paranoid ideation
|
Women
|
0.65
|
0.44
|
0.90
|
1.18
|
-0.25
|
0.46
|
-0.54
|
n.s.
|
-0.27
|
|
|
Men
|
1.13
|
0.61
|
0.80
|
0.53
|
0.33
|
0.07
|
5.00
|
n.s.
|
2.89
|
|
Psychoticism
|
Women
|
1.00
|
1.01
|
0.60
|
0.95
|
0.40
|
0.28
|
1.41
|
n.s.
|
0.71
|
|
|
Men
|
1.07
|
1.03
|
0.67
|
0.83
|
0.40
|
0.12
|
3.46
|
n.s.
|
2.00
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Note. BSI= Brief Symptom Inventory, t1 = admission of therapy, t2 = termination of therapy, n = 4 for women. n = 3 for men, possible range: 0-4, M = Mean, SD = Standard deviation, GSI = Global Severity Index, SE = Standard error, T = t-value.
3.3. Association between demographic and clinical variables and symptom change
There were no associations between age, length of partnership, education, housing, substance use, comorbidity, presence of Hepatitis B and C, treatment length and symptom change in BSI.