SYSTEMIC COUPL E THERAPY
AN D DEPRESSION
Othe r title s in th e
Systemic Thinking and Practice Series
edited by Davi d Campbel l & Ros Drape r published and distributed by Karna c
Asen , E. , Dawson , N. , & McHugh , B . Multiple Family Therapy: The Marlborough Model and Its Wider Applications
Bentovim , A . Trauma-Organized Systems. Systemic Understanding of Family Violence: Physical and Sexual Abuse
Burck , C , &c Daniel , G . Gender and Family Therapy
Campbell , D. , Draper , R. , & Huffington , C Second Thoughts on the Theory and Practice of the Milan Approach to Family Therapy
Campbell , D. , Draper , R. , & Huffington , C Teaching Systemic Thinking
Cecchin , G. , Lane , G. , & Ray , W . A . The Cybernetics of Prejudices in the Practice of Psychotherapy
Cecchin , G. , Lane , G. , & Ray , W . A . Irreverence: A Strategy for Therapists' Survival
Dallos , R . Interacting Stories: Narratives, Family Beliefs, and Therapy
Draper , R. , Gower , M. , & Huffington , C Teaching Family Therapy
Farmer , C Psychodrama and Systemic Therapy
Flaskas , C , & Perlesz , A . (Eds. ) The Therapeutic Relationship in Systemic Therapy
Fredman , G . Death Talk: Conversations with Children and Families
Hildebrand , J . Bridging the Gap: A Training Module in Personal and Professional Development
Hoffman , L . Exchanging Voices: A Collaborative Approach to Family Therapy
Jones , E . Working with Adult Survivors of Child Sexual Abuse
Jones , E. , & Asen , E . Systemic Couple Therapy and Depression
Krause , I.-B . Culture and System in Family Therapy
Robinson , M . Divorce as Family Transition: When Private Sorrow Becomes a Public Matter
Smith , G . Systemic Approaches to Training in Child Protection
Wilson , J . Child-Focused Practice: A Collaborative Systemic Approach
Work with Organizations
Campbell , D . Learning Considtation: A Systemic Framework
Campbell , D . The Socially Constructed Organization
Campbell , D. , Coldicott , T. , & Kinsella , K . Systemic Work with Organizations: A New Model for Managers and Change Agents
Campbell , D. , Draper , R. , & Huffington , C. A Systemic Approach to Consultation
Cooklin , A . Changing Organizations: Clinicians as Agents of Change
Haslebo , G. , & Nielsen , K . S . Systems and Meaning: Consulting in Organizations
Huffington , C , & Brauoning, H . (Eds. ) Internal Consultancy in the Public Sector: Case Studies
McCaughan , N. , & Palmer , B . Systems Thinking for Harassed Managers
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SYSTEMI C COUPL E THERAP Y
AN D DEPRESSIO N
Elsa Jones and Eia Asen
Forewor d b y
Gianfranco Cecchin
Introductio n b y Julian Leff
Systemic Thinkin g an d Practic e Series
Serie s Editor s David Campbell & Ros Draper
Londo n & Ne w Yor k
KARNA C BOOKS
First published in 2000 by H . Karna c (Books ) Ltd , 118 Finchle y Road , Londo n NW 3 5H T
Reprinted 2002
©2000 Elsa Jones and Eia Asen
The rights of Elsa Jones and Eia Asen to be identified as the authors o f this work have been asserted in accordance with §§ 77 and 78 of the Copyright Design and Patents Act 1988.
Al l rights reserved N o part o f this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission o f the publisher.
British Library Cataloguing in Publication Data
A CLP for this book is available from the British Library
ISBN: 978 1 85575 221 4
Edited, designed, and produced by Communication Crafts www . karnacbooks .com
Printed and bound in Great Britain by Antony Rowe Ltd, Eastbourne
ACKNOWLEDGEMENT
W e woul d lik e t o than k Julia n Lef f an d hi s tea m a t th e Institut e o f Psychiatry , London , fo r decidin g t o tur n thei r researc h len s ont o systemi c therap y an d fo r carryin g ou t thei r wor k t o th e highes t scientifi c standard . W e hav e foun d thei r encouragemen t ver y supportive .
ACKNOWLEDGEMENT
EDITORS7 FOREWORD
FOREWORD b y Gianfranc o Cecchi n x i
INTRODUCTION
Th e excitemen t surroundin g th e publicatio n o f thi s boo k stem s fro m th e fac t tha t i t i s base d upo n a recen t researc h projec t tha t demonstrate d th e effectivenes s o f systemi c therapy . Th e new s o f Els a Jone s an d Ei a Asen' s projec t an d th e subsequen t result s wer e greete d wit h grea t enthusias m i n th e systemic/famil y therap y field . Thei r wor k wa s bold , innovative , an d vital . Whe n w e hear d th e result s o f th e study , man y o f u s wer e askin g th e authors , "Ho w di d yo u d o it?"—an d thi s boo k i s thei r repl y t o tha t question .
Th e boo k i s abou t th e coupl e therap y itself , ho w i t wa s conceptualized , an d ho w i t wa s carrie d out , an d i t i s writte n wit h therapist s i n mind . Jone s an d Ase n hav e mad e thei r approac h t o marita l therap y accessibl e t o practitioner s b y describin g th e variet y o f technique s the y use d i n thei r work , an d b y analysin g severa l case s i n grea t detai l t o highligh t th e proces s o f thei r therapy . Bu t eve n thoug h th e therap y wa s conducte d withi n th e framewor k o f a manual , ther e i s a surprisin g amoun t o f variatio n i n th e approache s use d b y th e authors , an d thi s culminate s i n a n illuminat
X EDITORS ' FOREWOR D
in g dialogu e a t th e en d o f th e boo k i n whic h thes e difference s ar e explore d fully .
A s Editors , i t i s a pleasur e t o brin g int o th e serie s a boo k tha t s o clearl y unite s th e researcher' s rigorou s pursui t o f understandin g wit h th e therapist' s desir e t o hel p peopl e change . Man y therapist s wor k i n th e publi c secto r wher e th e paymaste r i s increasingl y askin g fo r th e evidenc e t o prov e tha t therap y i s wort h payin g for . Thi s i s a questio n tha t mus t b e answere d i f th e systemi c therapie s ar e t o hav e a futur e withi n th e publi c services , an d thi s boo k i s on e voic e tha t answer s th e quer y bu t als o provide s therapist s wit h a detaile d presentatio n o f way s t o wor k effectivel y wit h couples .
David Campbell Ros Draper London June 2000
Gianfranco Cecchin
Thi s boo k create d b y Els a Jone s an d Ei a Ase n provide s man y opportunitie s fo r a systemi c therapis t t o reflec t abou t man y issue s tha t ar e usuall y source s fo r discussion s an d controversy . On e importan t questio n tha t mus t b e considere d i s ho w man y restriction s a systemi c therapis t ca n tolerate , sinc e h e o r sh e i s usuall y accuse d of :
1. no t havin g a clea r pla n o f therap y an d no t bein g goal-oriented ;
2 . no t needin g t o hav e a precis e diagnosi s t o b e abl e t o function ;
3 . taking , mor e ofte n tha n not , a positio n o f neutrality—tha t is , havin g a lo w leve l o f indignatio n i n th e fac e o f th e terribl e thing s human s d o t o eac h other ;
4 . no t bein g strategic—tha t is , no t havin g a clea r intentionality .
Instead , i n thi s researc h projec t w e ca n appreciat e th e grea t valu e ther e i s i n creatin g artificia l restriction s tha t hav e th e paradoxica l effec t o f givin g grea t freedo m t o th e therapist s involved . x i
Th e boundarie s ar e create d b y a n independen t agency—th e tea m o f researchers . Thes e boundarie s permi t th e following :
• A diagnosi s i s mad e b y th e psychiatri c authoritie s
• Ther e i s a settin g (psychiatri c hospita l o r clinic ) define d b y th e agenc y
• Ther e i s a goal , th e specifi c goa l o f th e researc h project , understandabl e b y everyon e involved—namely , ca n a partne r b e o f hel p t o someon e wh o suffer s fro m a ver y common , well-know n devastatin g illness : depression ?
Th e nee d t o follo w researc h criteri a a s precis e a s possibl e als o offer s th e opportunit y t o inven t precis e rules . On e suc h rule , fo r example , is : th e numbe r o f session s i s regulate d no t b y th e nee d o f eac h clien t bu t b y th e requirement s o f th e researc h project . Th e sam e goe s fo r th e lengt h o f therap y ( 9 months ) an d th e flexibilit y o f th e participatio n i n th e projec t (e.g . ho w man y time s peopl e ca n atten d a s a coupl e o r alone) .
Withi n al l thes e artificia l limit s impose d b y th e researc h model , Ei a an d Els a ac t wit h grea t freedo m an d creativity , a s demonstrate d i n thi s beautifu l book . Th e tw o authors , wit h thei r clearl y differen t styles , prejudices , an d attitude s handl e themselve s wit h eas e withi n th e mysteries , th e contradictions , an d th e unpredictabilit y o f th e storie s brough t t o the m b y th e so-calle d "patients" — storie s tha t eithe r ar e tragi c o r comi c o r ar e tragi c an d comi c a t th e sam e time .
Th e result s o f th e researc h ar e no t th e responsibilit y o f th e therapists : i t i s th e jo b o f th e researcher s t o stud y th e results , an d the y hav e n o othe r goa l tha n t o fin d ou t i f thi s typ e o f therap y work s wit h depresse d persons . Th e therapist s themselve s ar e no t committe d t o demonstrat e anything . Th e impressio n the y giv e i s tha t the y woul d behav e i n th e sam e wa y i n anothe r context . I ris k th e hypothesi s tha t Els a an d Ei a woul d no t hav e change d thei r behaviou r eve n i f the y ha d foun d ou t tha t th e result s o f th e researc h wer e no t a s positiv e a s i n realit y the y turne d ou t t o be .
Anothe r interestin g constrain t dictate d b y th e researc h mode l i s tha t thi s so-calle d systemi c therap y ough t t o b e recognize d b y a n independen t observer . B y viewin g videotape d sessions , Professo r
FOREWOR D Xii i
Lef f s tea m was , i n fact , abl e t o recogniz e Ei a an d Elsa' s styl e a s bein g distinctl y differen t fro m th e styl e observe d i n session s conducte d b y a cognitiv e o r a dru g therapist . Eve n i f Els a an d Ei a ar e quit e differen t fro m eac h other , ther e mus t stil l b e som e principle s tha t bot h o f the m follo w i n a natura l way . I dar e sugges t tha t thes e principle s ar e th e classica l ones ; belie f tha t th e worl d w e se e i s a worl d o f communication , tha t peopl e exist , play , an d suffe r i n relatio n t o someone , an d tha t th e jo b o f th e therapis t i s t o b e curiou s an d fascinate d b y th e struggle s o f hi s o r he r client s withou t inducin g a wis h necessaril y t o chang e them .
Withi n thes e premises , w e ca n se e ho w eac h o f th e style s o f th e author s become s ver y coherent : th e fas t an d ironi c styl e o f Eia , o r th e participatio n i n huma n sufferin g o f Elsa . Elsa' s indignatio n i n th e fac e o f violence , abuse , an d povert y come s throug h ver y clearl y an d ver y consistentl y withi n thes e premises . Fo r me , al l thi s demonstrate s tha t someon e ca n b e totall y fre e t o us e hi s o r he r ow n styl e withou t givin g u p th e basi c principle s o f systemi c thinking .
Th e proble m w e ofte n have—namely , o f ho w importan t i t is , t o b e abl e t o work , t o hav e a diagnosis—i s resolve d her e i n a ver y brillian t way . Systemi c therapist s hav e alway s ha d th e doubt—o r th e conviction—tha t th e ac t o f labellin g a perso n wit h a diagnosi s contribute s t o th e problem s tha t th e perso n has . Sometimes , th e diagnosi s i s a s responsibl e fo r initiatin g a perso n int o th e caree r o f th e chroni c deviant , th e menta l patient , th e criminal , an d s o forth . I n thi s book , w e d o no t se e an y attemp t t o tak e awa y th e diagnosi s fro m people , a diagnosi s tha t sometime s ha s bee n wit h the m fo r years . I n on e cas e describe d here , th e diagnosi s become s a membe r o f th e famil y an d i s accepte d a s a long-ter m an d indispensabl e companio n i n life .
Thi s researc h i s perhap s demonstratin g th e strang e fac t tha t therapie s don e unde r som e for m o f stron g constraint s (courtmandate d cases , consultation s wit h prisoners , o r therapie s don e i n menta l hospitals ) sometime s produc e bette r result s tha n therapie s don e unde r mor e "collaborative " circumstances . I t coul d als o b e tha t th e therapis t i s constraine d i f no t constricte d b y man y rules , som e o f whic h ma y eve n b e liberating—fo r example , th e rul e tha t th e therapis t i s no t oblige d t o succee d i n curin g people . I n thi s
The Londo n Depression
Interventio n Trial : design an d finding s
Th e Londo n Depressio n Interventio n Tria l (LDIT : Lef f e t al. , i n press ) wa s se t u p i n 199 1 t o compar e th e effectivenes s o f antidepressan t drugs , individua l cognitiv e behaviou r therap y (CBT) , an d systemi c coupl e therapy . Patient s diagnose d a s "depressed " b y psychiatrist s wer e randoml y assigne d t o on e o f thes e thre e treatmen t modalities . However , th e CB T ar m o f th e tria l ha d t o b e stoppe d a t a n earl y stag e becaus e th e drop-ou t rat e wa s s o hig h ( 8 ou t o f th e firs t 11 cases) . Th e fina l comparison , therefore , wa s betwee n dru g therap y an d systemi c coupl e therap y an d involve d 8 8 subject s wh o me t th e researc h criteri a an d wer e take n int o treatment .
On e o f th e majo r finding s wa s tha t depresse d peopl e see n i n systemi c coupl e therap y di d significantl y bette r tha n thos e treate d wit h CB T o r antidepressan t medication . I t wa s becaus e o f thes e encouragin g result s fo r coupl e therap y tha t w e decide d t o writ e thi s book .
SYSTEMIC COUPLE THERAPY AND DEPRESSION
Background of the study
Al l researc h project s hav e thei r ow n histories . The y com e t o lif e
i n specifi c contexts , fo r specifi c reasons . Julia n Leff , professo r o f psychiatr y an d a n internationall y know n researcher , ha s bee n involve d fo r man y year s i n furtherin g th e understandin g an d clinica l usefulnes s o f th e concep t o f Expresse d Emotio n (EE ) i n
researc h o n familie s an d person s diagnose d a s sufferin g fro m
schizophreni a (Leff , Kuipers , Berkowitz , Eberleinfries , & Sturgeon , 1982) . Ther e ha s bee n som e researc h suppor t fo r th e hypothesi s tha t E E migh t b e relevan t i n workin g wit h depresse d patient s an d thei r ke y relatives . Thi s le d t o th e settin g u p o f th e LDI T t o determin e whethe r intervenin g wit h a famil y membe r o r partne r migh t hav e beneficia l effect s o n th e designate d patient' s depressiv e symptom s i f th e partner' s E E wa s reduced . Thi s i s wher e anothe r piec e o f histor y come s in . I n th e mid19805 , Julia n Lef f an d th e Marlboroug h Famil y Servic e tea m i n London , a grou p o f therapist s workin g systemicall y i n a communit y setting , jointl y engage d i n researchin g th e outcom e o f thei r therapeuti c work . E E wa s use d t o measur e aspect s o f th e coupl e (dyadic ) relationship , an d th e stud y showe d tha t E E (an d Critica l
Comment s i n particular ) wa s reduce d i n couple s an d familie s presentin g problem s rangin g fro m emotiona l an d conduc t disorder s i n children , t o eatin g disorders , marita l discord , an d famil y violence . Thes e result s provide d furthe r encouragemen t t o investigat e th e relationshi p betwee n depressio n an d E E an d t o determin e whethe r th e existenc e o f suc h a relationshi p migh t infor m therapeuti c practice . Ei a Ase n wa s on e o f th e Marlboroug h tea m involve d i n th e stud y (Ase n e t al. , 1991 ) an d wa s therefor e approache d b y Julia n Lef f t o se t u p th e pilo t phas e o f th e LDIT . Els a Jone s joine d th e projec t afte r th e pilo t phase . Becaus e cognitiv e behaviou r therap y an d pharmacotherap y wit h a psychoeducationa l componen t ha d alread y bee n manualized , i t wa s necessar y fo r systemi c coupl e therap y als o t o b e describe d i n a manualize d for m (se e chapte r two) . N o controlle d studie s ha d bee n carrie d ou t evaluatin g whethe r systemi c therap y wa s o f an y us e wit h depresse d patients . Becaus e n o standardize d treatment s existed , th e developmen t o f a treatmen t manua l fo r thi s
TH E LONDO N DEPRESSIO N INTERVENTIO N TRIA L
for m o f therap y wa s a preconditio n fo r th e fundin g o f th e stud y b y th e bod y providin g th e grant—th e Medica l Researc h Council . Versio n 1 o f th e manua l wa s exactl y on e pag e long , sinc e i t seeme d impossibl e t o mak e concret e th e ar t o f therapy . However , thi s versio n wa s no t acceptabl e t o th e researchers , a s i t wa s though t t o b e "to o vague" . Versio n 2 wen t t o th e opposit e extreme : ove r 10 0 pages , narrowl y printed , obsessionall y detailin g ever y possibl e therapeuti c manoeuvre , wit h for m o f words , tone , pac e o f
deliver y al l prescribed . Whe n tryin g thi s out , i t emerge d tha t no t eve n th e write r o f th e manua l coul d possibl y hav e an y hop e o f adherin g consistentl y t o it . A t thi s point , Els a Jone s joine d th e projec t an d provide d a differen t perspective . Ove r a perio d o f nin e months , ne w idea s an d technique s wer e introduce d an d the n modifie d b y bot h o f u s unti l agreemen t ha d bee n reache d o n a versio n tha t w e coul d bot h subscrib e to .
Writin g a treatmen t manua l i s on e thing , bu t adherin g t o i t i s another . Adherenc e t o a manua l o r protoco l i s importan t i n researc h s o tha t result s ca n b e compared . I t make s i t possibl e t o replicat e researc h an d t o asses s whethe r treatmen t model s bein g compare d ar e significantl y differen t fro m on e another . Consequently , eac h sessio n wa s videotaped , an d tape s wer e randoml y selecte d b y a n independen t rate r t o chec k fo r treatmen t adherenc e an d treatmen t integrity . Thi s include d lookin g a t fiftee n session s wit h a tota l tim e o f 1,02 6 minute s fo r CBT , thirty-eigh t session s wit h 1,97 1 minute s fo r coupl e therapy , an d forty-seve n session s wit h 1,44 5 minute s fo r dru g therapy . Thi s researc h (Schwarzenbac h & Leff , 1995 ) conclude d tha t i t wa s possibl e t o distinguis h clearl y betwee n differen t models . Eac h mode l wa s demonstrabl y characteristi c o f itsel f an d no t o f th e othe r models . I t wa s als o foun d tha t th e therapist s adhere d t o th e manua l bu t als o occasionall y use d som e technique s fro m othe r therapies . Therefore , despit e ou r difficultie s i n comin g t o term s wit h writin g a manual , thi s researc h demonstrate d tha t i t wa s possibl e t o describ e wha t w e di d i n suc h a wa y tha t th e descriptio n encompasse d ou r wor k bu t di d no t overla p wit h tha t o f th e othe r modalities .
Method
Th e LDI T involve d a n initia l baselin e assessmen t o f depresse d patient s an d thei r partners , followe d b y a n interventio n (treatment ) phase . Patient s wer e assesse d a t th e en d o f treatmen t an d agai n afte r a twelve - t o fifteen-mont h perio d o f n o treatment . Th e treatmen t phas e consiste d o f a maximu m o f nin e month s o r twent y session s fo r coupl e therap y an d CBT , an d on e yea r fo r antidepressan t medication . Patient s allocate d t o on e o f th e treatment s wer e no t permitte d t o receiv e an y othe r treatmen t simultaneously . I n othe r words , thos e patient s see n fo r coupl e therap y di d no t receiv e an y antidepressan t o r othe r pyschotropi c medication . I n th e twelv e month s afte r completio n o f treatment , i t wa s permitte d t o offe r a maximu m o f tw o booste r sessions .
Patient s ha d t o mee t criteri a fo r depressio n a s measure d b y th e Presen t Stat e examination , th e Hamilto n Depressio n Ratin g Scale , an d th e Bec k Depressio n Inventor y (BDI) . Th e threshol d fo r significan t depressio n o n th e BD I wa s se t a t 11 . Partner s wer e assesse d o n th e BD I an d th e Camberwel l Famil y Intervie w (Vaugh n & Leff , 1976) , an d patient s an d partner s wer e assesse d o n th e Dyadi c Adjustmen t Scale . Th e partne r ha d t o b e rate d a s expressin g a t leas t tw o Critica l Comment s (hig h EE ) durin g th e Camberwel l Famil y Intervie w (Vaugh n & Leff , 1976) . I n additio n t o thes e baselin e assessments , al l patients—and , i n coupl e therapy , als o thei r partners—wer e give n six-weekl y BD I assessment s t o plo t th e cours e o f moo d change s durin g th e treatmen t phase . Followin g terminatio n o f treatment , three-monthl y BDI s wer e don e b y th e researcher s unti l th e follow-u p assessment . Subject s wer e exclude d fo r a variet y o f reasons , includin g psychoti c features , bipola r illness , organi c brai n syndrome , an d primar y substanc e abuse . Th e subject s wh o wer e include d me t th e psychiatri c criteri a fo r significan t depressiv e illness . Patient s allocate d t o th e differen t treatment s wer e matche d o n al l relevan t characteristics , suc h a s ag e o f patien t an d partner , se x o f patient , an d chronicit y an d severit y o f depression . Al l therapist s o f th e thre e differen t treatmen t modalitie s (CBT , antidepressan t drugs , systemi c coupl e therapy ) agree d tha t th e sampl e seeme d biase d toward s th e heav y en d o f th e spectrum , wit h man y o f th e patient s havin g lon g psychiatri c
historie s an d bein g significantl y distresse d an d sociall y disadvantaged . Th e presenc e o f particularl y difficul t patient s enterin g researc h project s i s no t a n unfamilia r finding , an d w e discus s som e o f th e implication s below .
Results
O n a numbe r o f differen t measures , coupl e therap y prove d t o b e mor e effectiv e an d acceptabl e tha n antidepressan t medication . Patient s participatin g i n coupl e therap y wer e les s depresse d a t th e en d o f treatmen t an d o n two-yea r follow-up .
Patient s receivin g antidepressan t medicatio n droppe d ou t a t a muc h mor e significan t rat e (56.8% ) tha n thos e i n coupl e therap y (15%) . A fulle r discussio n o f th e complexit y an d wealt h o f dat a ca n b e foun d i n th e researc h pape r b y Lef f e t al . (i n press) . A healt h economi c analysi s showe d tha t antidepressan t treatmen t i s n o cheape r tha n systemi c coupl e therapy .
Figur e 1.1 graphicall y illustrate s th e difference s betwee n th e tw o treatmen t modalitie s a s measure d b y th e BDI . I t ca n b e see n tha t o n averag e ther e i s a dramati c dro p i n depressiv e symptomar 1 1
Baselin e On e yea r Tw o yea r Occasio n
FIGUR E 1.1 Mea n profile s o f coupl e an d medica l treatmen t group s
tolog y i n the coupl e therap y group , no t onl y a t the en d of treatmen t but , perhap s mor e strikingly , at two-yea r follow-up .
What do the findings mean?
Th e majo r findin g of the stud y ha s to be th e reductio n i n depressio n i n the patient s receivin g thi s diagnosis . However , a numbe r of othe r finding s see m to u s wort h discussing .
Expressed Emotion
Di d E E chang e durin g o r after the differen t treatments ? Th e numbe r of Critica l Comments , s o crucia l i n th e wor k wit h familie s containin g a perso n diagnose d as schizophrenic , wa s foun d not to b e relate d to change . I n som e of the couple s wit h dramati c reductio n i n depressiv e symptoms , th e numbe r o f Critica l Comment s wen t up , i n other s nothin g changed , an d of cours e ther e wer e thos e wher e ther e wa s a reduction . However , ther e wa s a significan t chang e i n anothe r dimensio n of EE : th e leve l of Hostilit y wa s significantl y reduce d i n the couples ' grou p as compare d wit h the grou p of patient s receivin g antidepressan t medication . Systemi c therap y appear s to affect hostilit y expresse d b y partner s o f depresse d patients .
The costs of treatments
A healt h economi c analysi s wa s buil t int o th e researc h projec t fro m th e ver y outset . Th e cos t of coupl e therap y wa s calculate d o n th e basi s of th e averag e numbe r an d duratio n o f session s (1 2 sessions , 60 minutes ) an d the uni t cos t of direc t therapis t contac t time . Al l prescribe d antidepressant s (an d associate d bloo d tests ) plu s th e prescribin g psychiatrist' s tim e wer e co s ted . Servic e utilizatio n dat a wer e collecte d durin g therap y an d o n follow-up , coverin g a rang e of ke y healt h an d socia l car e service s (in-/out-/day-patien t hospita l services ; da y care ; contact s wit h a GP , communit y psychi
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CHRONIC MOIST ECZEMA (IMPETIGO) AT THE MANE AND TAIL.
Fleshy neck, thick mane and tail, lymphatic constitution, profuse perspiration, lack of cleanliness, alkaline soaps, plethora, foul stable, pus microbes. Symptoms: itching or tenderness, shedding hair, thinning of mane and tail, skin thickened, ridges and folds, tenderness, moisture, crusts raise hairs from follicles, fœtor, sores and ulcers, matted hairs. Treatment: remove general and local causes, cleanse, cool, pure stable, clip, reduce grain; cooling, laxative food, soothing or stimulating applications, zinc oxide, talc, olive oil and diachylon plaster, iodoform, silver nitrate, oil of cade, or of white birch, sulphur iodide, Canada balsam and sulphur, green soap, dusting powders, ointments.
This condition is especially common in horses with a profusion of long hairs in the mane and tail, and in the heavy draught animal with a thick, fleshy neck. In such the skin is very sensitive, and when profuse perspiration soaks the skin, or concretes and decomposes about the roots of the hairs, the local irritation necessary to the production of the eruption is present. A lack of careful grooming is therefore a common cause, yet soap left in washing the mane or tail may be no less injurious. Plethora has its influence in many cases, and the ammoniacal fumes from a wooden stable saturated with excretions are not to be ignored. Finally in cases accompanied by pustular eruption, the pus microbes must be recognized as factors. Symptoms. There may be marked itching or extreme tenderness of the part affected or in the absence of both there may occur a gradual shedding of the long hairs, so that an increasing thinness of the mane and tail (rat tail) becomes apparent. The skin covering the affected parts is thickened, inflamed and thrown into ridges and folds, one rubbing against another. The surface feels moist or is covered by crusts formed by the condensation of the moist exudate, and embracing the hairs and drawing them out of their follicles. Beneath
the concretions the skin is soaked in the tenacious fœtid liquid discharge. The hair follicles become atrophied in connection with the evulsion of the hairs, or under congestion the hairs stand rigidly erect, and bristly or curly. As the freer secretion abates, the exudate become more purely scally or encrusted, but the skin remains thickened and thrown into folds. Under the inveterate rubbing or gnawing the skin is often extensively abraded and large open sores are formed which are indolent and slow to heal. That matting together of the hairs which has been known as plica Polonica is often the result of the disease of the hair follicles and the accumulation of scabs which takes place in this disease, rather than to a special infection like gregarina (coccidiosis).
Treatment. The first consideration must be to remove all general and local causes of eczema, insure perfect cleanliness and good grooming in any case in which these may been lacking, purify the air of the stable if that has been foul, procure a cool environment when that has been too hot, clip the patient if habitually soaked with perspiration by reason of a heavy coat, suspend or moderate the work if that has been too exacting, withhold a heating grain ration (corn, buckwheat, barley, wheat, peas, beans), and furnish cooling, laxative, easily digested food. In the cases before us the acute, irritable stage has usually passed, so that the more stimulating applications may be safely used, yet in many old standing cases a fresh eruption may have taken place, which would demand for a time the most soothing applications only. Apart from such cases the more stimulating dressings are applied at once.
The affected surface is exposed by clipping or shaving off the long hairs, thus at once removing a source of heat and irritation and allowing of the direct and thorough application of the dressing. Among the astringent and stimulant applications oxide of zinc ointment and benzoated oxide of zinc are among the simplest and least likely to irritate, but the stronger applications can usually be borne. The Lassar paste consists of two parts each of finely powdered talc and zinc oxide, four parts of vaseline and three per cent. of salicylic acid. Oxide of bismuth may substitute the zinc oxide. Three parts of olive oil and four of diachylon plaster melted together and stirred until cool, makes another mildly astringent and sedative application. Iodoform 1 dr. to an ounce of vaseline is an excellent
agent. A mixture of iodoform and tannin is used as a dusting powder by Friedberger and Fröhner: or silver nitrate solution (6:100) may be used. Tar ointment (1:8) with a little subcarbonate of potassium added makes an excellent application. Oil of cade and oil of white birch may be used in the same way, the latter being the most desirable as a rule. Ammonia chloride of mercury as an ointment (1:10), often acts well and the black wash, formed by the decomposition of calomel with potash is often serviceable. Iodide of sulphur and vaseline (1:10) is often an excellent resort. An ointment of equal parts of Canada balsam and sulphur or iodide of sulphur in four parts of vaseline is often effective. Other valuable preparations are ointments (10%) of ichthyol, naphthol, chrysarobin or pyrogallol. Hebra’s last resort of green soap is never to be forgotten, the affected skin being thickly smeared with the soap which is left to dry on, and is repeated and rubbed in, for several days in succession. It may seem at first to aggravate the disease by reason of the solution and removal of the covering of the vesicles or pustules and the exposure of a pink sensitive surface, but day by day this improves and the skin becomes smooth and more natural. After a few days of this treatment, it may, if necessary, be followed by astringent or stimulant dressings, or the varied medicaments may be incorporated with the soap so as to form one dressing to be applied from the first. When a healthy action has been once established, all that is required further may be cleanliness, with the use of bland dusting powders or ointments to establish the cure.
CHRONIC ECZEMA OF THE CARPUS AND TARSUS; MALANDERS: SALLENDERS.
Eruption in bends of carpus and tarsus and downward: Causes: lymphatic temperament, constitutional predisposition, deranged internal organs, excessive secretions, modified, congested skin, friction between dermal folds. Symptoms: stiffness, heat, thickening and redness, vesicles or oozing, crusts, erect hairs, shedding hair, squamæ, cracks, abrasions, fissures, subcutaneous engorgement, lymphangiectasis. Treatment: Cleanse, get pure air, regular exercise, nonstimulating food, avoid cold water, mud, slush, caustic soap, lime, sharp sand, foul organic matter. Massage. Light bandages. Bland ointments. Dusting powders. Rest. Iodoform. Starch. Zinc oxide. Boric acid. Magnesia. Bismuth. Lycopodion. Lead. Tannin. Pyoktannin. Stimulating ointments. Green soap. Arsenic.
The bends of the carpus and tarsus in heavy, lymphatic, coarse skinned horses are especially subject to eczema followed by a dense scabby eruption, which in the old farrier’s nomenclature was known as malanders in the fore limb and sallenders in the hind. It is not always confined to the joints but may extend down the limb, especially on the back, where the hair is coarser and the skin thicker, as far as the fetlock or even to the hoof.
In the matter of causation much depends on the general constitutional state which tends to eczema, and on the torpor or derangement of some of the internal organs the functions of which are interdependent with those of the skin. Something too must be attributed to the freer secretions of these parts in coarse bred horses, to the accumulation of such secretions and of extraneous irritants under the long hair, to the sluggishness of the circulation in the limbs which has to overcome the force of gravitation, and to friction between the thick folds of skin in flexion, and stretching in extension. Swelling of the lower limbs is at once a cause and an effect of the disease.
Symptoms. At the outset the animal may be seen to move rather stiffly, and the skin is found to be hot, thickened and if white reddened. Soon a close observation may detect the eruption of vesicles, or simply an oozing of a yellowish or bloody serum which concretes around the hairs forming an encrusted covering for the part, holding the hairs erect and bristly, and even lifting them out of their follicles. Cracks also appear in the depth of the fold, leading to a more abundant exudate, and the disease may extend around the whole surface of the limb.
In the more acute cases this may be followed by more or less depilation, dessication and recovery, but too often the condition becomes chronic, the thickened, encrusted or squamous skin continues to exude, crack and cover itself with crusts, under which the decomposing liquids macerate and irritate the exposed cuticle, and engorgment of the whole limb with hyperplasia of the connective tissue and lymphatic plexus and vessels is the result. This hyperplasia of the skin and connective tissue (elephantiasis) is also a common result of lymphangitis.
Treatment. As in other skin affections attention must first be given to removal of the causes. Ensure cleanliness, pure air, regular exercise, non-stimulating food, the avoidance of cold water, melting snow, soapy washes and all other sources of irritation. Deep mud, especially if charged with lime, sharp sand, decomposing organic matter or other irritant, is particularly offensive.
Hand-rubbing (massage) of the limbs and evenly applied light bandages are often of the greatest value in dispersing or obviating swelling.
The slighter attacks may be met at the outset by bland ointments or dusting powders and rest from all but necessary exercise. Dressing with iodoform may bring about a recovery in a few days. Starch and oxide of zinc, boric acid, magnesia carbonate, bismuth or lycopodion may give good service. Lotions of lead acetate, tannin, iron sulphate, alum, potassium permanganate or pyoktannin may be used as in other forms of eczema. In obstinate cases green soap followed by stimulating ointments or liniments, tar, oil of white birch, Canada balsam, turpentine and glycerine, oil of cade, etc., will often serve an excellent purpose. In these advanced cases an alterative such as arsenic may be employed.
ECZEMA OF ALIMENTARY ORIGIN IN CATTLE. STARVATION MANGE. STALK DISEASE. MALT ECZEMA. POTATO ECZEMA.
In low condition: erythema, hæmorrhagic extravasations, or vesicles on tail, lips, fore legs, udder. Trombidium holosericeum. Malt or potato eczema: marc eczema on legs and body. Causes: feeding on marc only, skins, green potatoes, fermenting. Attack in ratio with marc eaten. Worst on new stock, and feeding cattle. Calves have diarrhœa, children eruption. Bean trefoil and milk sickness act similarly. Solanin. Unaffected by boiling. Season. Field. Chlorophyl. Narcosis absent. Is brain adaptable? Other ingredients inoperative. Eczema ceases with change of food: is not inoculable. Symptoms: fever, costiveness, inappetence, red mucosæ, weeping, stringy salivation, debility, emaciation, black diarrhœa. May lie with extended head, grinding teeth, tympany, lethargy, coma. Pig and dog vomit. Abortion. Redness, swelling, stiffness on pasterns: may extend to whole body: exudations: thick crusts: erect or shed hairs: rigid thickened, folded, cracked skin, buccal mucosa may suffer: abscess, sloughs. Mortality slight and up to 20 per cent. Lesions: congestions of small intestine, brain and muscle. Treatment: stop or lessen the marc adding grain: turn to pasture: locally bathe, cold or tepid: lead lotions: dusting powders: tannin: blue stone: creolin: cresol: tar or birch oil: carbolic acid.
The skin of cattle seems to suffer more than that of other animals in connection with the ingestion of poisons. In starved or very low conditioned animals, eruptions are met with which may be in the form of a simple erythema, a hæmorrhagic extravasation in spots, or an eruption on the end of the tail in the form of epidermic concretions or pustules (impetigo). Among the vineyards it is common to find an eruption with papules and vesicles on the lips, fore legs and udder of cows which were fed on the succulent young shoots and leaves of the grape vine. In cases of this disease, Railliet and Moreau have found a great number of the silky trombidium larvæ (harvest bug), and accordingly attribute the affection
exclusively to their attacks. The growth of the vine on the warmest and sunniest exposures, the most favorable to the propagation of this acarus, gives much support to this conclusion.
Malt or Potato Eczema. On the continent of Europe where potatoes are largely used for distillation and the production of starch, herds of cattle are fed often almost exclusively on the refuse or marc, and in such herds an eczematous eruption of the legs and exceptionally of the body is a familiar occurrence.
Causes. The disease has been definitely traced to an exclusive dietary on potato marc, and still more so to the skins, to tubers rendered green by exposure to the sun, and to the distillery potato refuse which has undergone fermentation. Thus 80 litres of the pulp daily without dry food will determine a violent attack in the animal consuming it, while the animal consuming 40 litres has it much milder (Friedberger and Fröhner). It attacks animals living in the best conditions of cleanliness and pure air, and the essentially toxic quality of the cause may be deduced from the fact that newly bought animals, which are not yet habituated to it suffer the most, that fattening cattle are the common victims, while work oxen which perspire more freely and milch cows escape, yet calves fed upon their milk may suffer from diarrhœa and infants from a cutaneous eruption (Johné). The poison it is to be inferred is eliminated in the milk. Similar examples of the protecting of the milch animal by elimination of the poison through the milk are found in bean trefoil (cytisus) which poisons the milk while proving harmless to the goat which yields it, and the poison of milk sickness which is deadly to cattle which are not giving milk, and harmless to the milch cow, yet deadly to those that consume her milk.
The exact nature of the poison is as yet uncertain, and as solanin is the only toxic principle so far discovered in potato, this has been held tentatively to be the essential cause. The amount of solanin in young and germinated potatoes has been given by Cornevin as follows: Germinated tubers Young tubers.
The toxic strength of the marc is not impaired by boiling, cooking or other culinary treatment, and the same is true of solanin. The toxicity is greatest after the potato has been subjected to germination, or when it has become green by exposure to the sun, and in these conditions the solanin is increased. The toxicity of the marc is higher in certain years, and in the product of certain fields, than in others, and this is in keeping with the effect of environment in modifying the products of a plant. The increased production of chlorophyl under the action of sunlight is associated with a material increase of the amount of solanin. Until therefore another toxic product can be shown to be the essential cause of this affection the solanin must be charged with this result. This conclusion would be more inviolable if the animals attacked showed other symptoms of solanin poisoning such as narcotism, vertigo, stupor and paralysis, and the absence of these may perhaps be due to the gradual advance of the toxic action, and the progressive immunizing of the animal system. The brain may be able to accommodate itself more readily than the skin.
The other constituents of the potato or of the marc fail to produce the eruption under other conditions: the alcohol in brewers and distillers’ grains, the acetic, lactic and butyric acids in the refuse of starch, beet sugar and canning factories, the potash in turnips and other roots, the yeast ferment in brewers’ grains. The acarus of foot mange (symbiotis bovis) is rarely present in the affected animal though the eruption in the same situation would strongly suggest its presence and lead to a search for it. Moreover the eczema appears at once in a large number of animals, affecting a large area without evidence of slow and steady progression and disappears with equal rapidity in many cases when the diet is changed. Finally the eczema has not been successfully propagated by inoculation which conveys mange infallibly from animal to animal.
Symptoms. The disease is associated with slight fever, costiveness, impaired appetite, hyperæmia of the mucosæ, epiphora, viscous salivation, muscular weakness, and finally emaciation and black diarrhœa. The gravity of these symptoms varies, being greater when the animals have eaten the leaves and stems, the raw potatoes in their skins, the young shoots and parings, or green potatoes which have been sunned. The animals may lie most of their time stretching
themselves out with head extended on the ground, they may grind the teeth, may have pulse small and rapid, tympany, lethargy, coma and even paraplegia but these severe symptoms are exceptional and almost altogether confined to the cattle of distilleries which receive an exclusive diet of potato marc. In the pig and dog vomiting has been noticed (Cornevin). Pregnant animals may abort.
The local symptoms begin with redness and swelling of the skin around the pasterns, especially of the hind limbs, stiffness and a disposition to lie most of the time; then small flattened vesicles appear, isolated or confluent, which bursting, form extended, raw patches the abundant exudations of which concrete into thick crusts. The hairs stand erect and are abnormally thick at their roots. The eruption may extend to the whole limb, the scrotum, mamma, tail and body at large, so that in severe cases it is practically universal. The skin becomes thick, rigid, hide bound, wrinkled and folded with intervening cracks. As a rule, however, the eruption is confined to the limbs, scrotum, mammæ and tail. In some extensive and persistent cases the buccal mucosa suffers, particularly on the pad on the upper jaw, which shows extensive and irregular ulcers with purulent centre and swollen, congested margin. Abscesses may develop in the skin and subcutem and sloughing of the integument is not unknown.
Mortality is slight as a change of food is usually made and a recovery ensues in a few weeks. Yet Baranski noted 20 per cent. of deaths in Galicia, mostly in old, worn out animals which had been stabled for a length of time.
Lesions. On examination, post mortem, there are found hyperæmia and inflammation of the small intestine, some congestion of the cerebral meninges, and a red, bloody condition of the muscular system.
Treatment. The toxic provender must be stopped, or reduced to 20 or 30 litres of pulp daily, supplemented by sound wholesome dry fodder. Marker claims that 70 quarts daily of the potato marc may be given if combined with a fair ration of Indian corn. Turning out doors to pastures usually effects a speedy cure.
Local treatment is rarely demanded but when the irritation is great it may be soothed by bathing with cold or tepid water, lead lotion, glycerine and lead lotion, or by the application of ointments of lead, tar, oil of cade or birch, or carbolic acid. Dusting powders of zinc
oxide, starch, lycopodium, boric and tannic acids may also be employed. Decoction of oak bark or solution of blue stone is often used, also creolin or cresol one part, to alcohol five parts.
It is rarely necessary to use other than the cooling and astringent lotions, yet the persistence of irritable sores, ulcers and crusts must be treated as in other chronic skin affections.
MOIST ECZEMA OF THE PASTERNS IN THE OX.
Causes: hot season, foul stables, streptococcus. Symptoms: sudden attack, red, swollen, warm, tender pastern, vesicles, crusts, scabs, lameness, foot rested on toe, cracks, fissures, interdigital foot rot, shedding hoof, scaly chronic form. Treatment: clean stables and yards, cleanse feet, lead lotion or zinc, phenol, iron or copper. Tar water, tar, creolin, creosote, iodol.
This affection is comparable to the simpler forms of grease or digital eczema in horses.
Causes. It occurs especially in the hot midsummer season in cattle kept in filthy stables, where the feet and pasterns are kept filthy and the air charged with irritant ammoniacal fumes. A streptococcus is usually met with and may be found in pure cultures in resulting abscesses.
Symptoms. The attack is sudden, the skin around the pastern becoming red, warm, swollen and tender, with the formation of vesicles, isolated or confluent, which rupture and discharge a serous exudate that dries up into crusts and scabs. Lameness is a marked symptom and in bad cases the swelling and pain are such that the foot may be habitually raised from the ground and rested only on the toe. The swollen skin is thrown into folds which rub on each other, and breaks open into cracks from which exudes a serous fluid that macerates and irritates the skin, the heel pad and the interdigital space, so as to determine interdigital foot rot. This may lead to inflammation inside the hoof with shedding of the horny mass, or it may subside into a chronic form with an abundant squamous product.
Treatment should be mainly prophylactic in the direction of cleanliness and abundant litter in the stables, and the avoidance of
pools of liquid manure and of septic mud puddles in the yards and roads.
In the early stages of the affection the pasterns and interdigital spaces should be thoroughly cleansed and covered with a bandage with a weak solution of acetate of lead, or of sulphate of zinc, or carbolic acid, or sulphate of iron or copper. In the more advanced stages tar water or crude tar will serve a good purpose, or watery or alcoholic solutions of creolin, creosote, oil of tar, carbolic acid or iodol. When the horn has been separated from the quick, it is usually best to pare away all such, to bevel the edges so as to make them less rigid and more pliant and to dress with tar water and later to cover with undiluted tar and bandage.
MOIST ECZEMA OF THE TAIL, NECK, CHINE AND DEWLAP OF CATTLE.
Definition. Causes: in work oxen, winter, foul stables; dairy cows on spoiled fodder or maize, wheat, buckwheat, cotton seed, etc. Contagion. Symptoms: skin hot, thick, tender, exuding, matted hair, vesicles, itching, excoriation, ulceration, bleeding, sloughing. Treatment: Soothing. Cleanliness. Pure air. Tepid sponging. Dusting powder. Clip or shave. Calomel with care. Phenol. Creolin. Silver or copper salts. Tannic or boric acid.
This is an acute eczematous eruption of cattle beginning as a congestion and swelling of the skin and advancing to an exudation or secretion which bedews the surface with a sticky discharge, and concretes into scabs and crusts.
Causes. The disease has been mainly seen in work oxen during winter, when kept in close, foul stables and not properly groomed. It is also seen in dairy cows and may be attributed to the indigestion and gastric disorders which come from the ingestion of spoiled fodders, or from a too stimulating diet, such as Indian corn, wheat, buckwheat, barley, cotton seed, and the seeds of the leguminosæ. Lafosse looked upon it as contagious, but Cadeac denies both this and its alimentary origin.
Symptoms. The attack is severe, the skin becoming swollen, hot and tender, especially at the base of the tail, on the neck, chine and forehead. Soon the turgid, congested skin exudes a somewhat glutinous serous product, which mats the hairs into tufts and exposes the intervening red, excoriated skin, with here and there vesicles singly or in groups. Itching is usually intense and the animal licks, rubs and scratches the affected surface unmercifully. The resulting excoriations and sores add greatly to the severity of the troubles, including ulceration, bleeding and even sloughing.
Treatment. Prophylaxis should be the first consideration, and in the acute stages of the disease, its arrest by soothing applications. Cleanliness, pure air, and tepid sponging, to be followed by a dusting powder of boric or salicylic acid, or a lotion of acetate of lead or sulphate of zinc may serve a good purpose. If the case proves obstinate, the hair may be clipped or shaved to allow of the more direct and thorough application of the dressings. Cadeac especially recommends an ointment of calomel (1 ∶ 10) but this must not be applied over an extended surface, nor must it be recklessly repeated owing to the dangerous susceptibility of the bovine race to mercurialism.
Lotions and ointments of carbolic acid are of great value in moderating the intense pruritus, and a combination of this with lead acetate will often prove quite effective. Lotions, liniments or ointments of tar, oil of cade, creosote, or creolin. When ulcers are present they may be treated by solutions of silver nitrate (2 ∶ 100) or cupric sulphate (2 ∶ 100) or powdered iodoform. When the exudate is excessive, astringent dusting powders often serve a good purpose; tannic acid and boric acid, with starch or lycopodion.
