Systemic Couple Therapy and Depression First

Edition. Edition Asen pdf download

https://textbookfull.com/product/systemic-couple-therapy-and-depression-first-edition-edition-asen/

★★★★★ 4.8/5.0 (38 reviews) ✓ 116 downloads ■ TOP RATED

"Amazing book, clear text and perfect formatting!" - John R.

DOWNLOAD EBOOK
 Systemic Couple Therapy and Depression First Edition.
Edition Asen pdf download

TEXTBOOK EBOOK TEXTBOOK FULL

Available Formats

■ PDF eBook Study Guide TextBook

EXCLUSIVE 2025 EDUCATIONAL COLLECTION - LIMITED TIME

INSTANT DOWNLOAD VIEW LIBRARY

Collection Highlights

Clinical Interventions in Systemic Couple and Family

Therapy Roberto Pereira

Supervision of Family Therapy and Systemic Practice 1st

Edition Arlene Vetere

The Practice of Emotionally Focused Couple Therapy

Creating Connection 3rd Edition Johnson

Creating Cultural Safety in Couple and Family Therapy

Supervision and Training 1st Edition Robert Allan
Long Term Systemic Therapy : Individuals, Couples and
Families Arlene Vetere

Doing Couple Therapy Craft and Creativity in Work with

Intimate Partners 2nd Edition Robert Taibbi

Self-System Therapy for Depression: Therapist Guide 1st

Edition Kari M. Eddington

Self-System Therapy for Depression: Client Workbook Kari

M. Eddington

The mindfulness and acceptance workbook for depression

using acceptance and commitment therapy to move through
depression and create a life worth living Second Edition
Robinson
.1 Y S T E M I C

AND PRACTICE
Series E d i t o r s :
D A V I D C A M P B E L L & Ros D R A P E R

Systemic Couple Therapy

and Depression
SYSTEMIC COUPLE THERAPY
A N D DEPRESSION
Other titles in the
Systemic Thinking and Practice Series
edited by David Campbell & Ros Draper
published and distributed by Karnac
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
Credit C a r d orders, Tel: +44 (0) 20-8969-4454; Fax: +44(0)20-8969-5585
Email: [email protected]
SYSTEMIC COUPLE THERAPY
A N D DEPRESSION

Elsa Jones and Eia Asen

F o r e w o r d by

Gianfranco Cecchin
Introduction by

Julian Leff

Systemic Thinking and Practice Series

Series Editors
David Campbell & Ros Draper

London & N e w York

KARNAC BOOKS
First published in 2000 by
H. K a r n a c ( B o o k s ) L t d ,
118 F i n c h l e y R o a d ,
L o n d o n NW3 5 H 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.

All 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 C L P . 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 w o u l d l i k e to t h a n k J u l i a n L e f f a n d h i s t e a m at the I n s t i t u t e of
P s y c h i a t r y , L o n d o n , for d e c i d i n g to t u r n t h e i r r e s e a r c h l e n s onto
s y s t e m i c t h e r a p y a n d for c a r r y i n g out their w o r k to the h i g h e s t
scientific s t a n d a r d . W e have found their e n c o u r a g e m e n t very
supportive.

v
CONTENTS

ACKNOWLEDGEMENT V

EDITORS
7
FOREWORD ix

FOREWORD by Gianfranco Cecchin xi

INTRODUCTION b y Julian Leff xv

Overture 1

CHAPTER ONE

T h e L o n d o n Depression Intervention Trial:

design a n d findings 3

CHAPTER TWO

T h e therapy manual 13

vii
Viii CONTENTS

C H A P T E R T H R E E

W o r k i n g w i t h depression, I
Elsa Jones 45

C H A P T E R F O U R

W o r k i n g w i t h depression, II
Eia Asen 77

C H A P T E R F I V E

Themes and variations 93

Finale 119

REFERENCES 123

INDEX 128
 EDITORS' FOREWORD

T
he excitement s u r r o u n d i n g the p u b l i c a t i o n of this b o o k
s t e m s f r o m the fact that it is b a s e d u p o n a recent r e s e a r c h
project that d e m o n s t r a t e d the effectiveness of systemic
t h e r a p y . T h e n e w s of E l s a Jones a n d E i a A s e n ' s project a n d the
s u b s e q u e n t r e s u l t s w e r e greeted w i t h great e n t h u s i a s m i n the s y s ­
t e m i c / f a m i l y t h e r a p y field. T h e i r w o r k w a s b o l d , i n n o v a t i v e , a n d
v i t a l . W h e n w e h e a r d the r e s u l t s of the s t u d y , m a n y of u s w e r e
a s k i n g the a u t h o r s , " H o w d i d y o u d o i t ? " — a n d this b o o k is t h e i r
r e p l y to that q u e s t i o n .
T h e b o o k is a b o u t the c o u p l e t h e r a p y itself, h o w it w a s c o n ­
c e p t u a l i z e d , a n d h o w it w a s c a r r i e d out, a n d it is w r i t t e n w i t h
t h e r a p i s t s i n m i n d . Jones a n d A s e n h a v e m a d e their a p p r o a c h to
m a r i t a l t h e r a p y accessible to p r a c t i t i o n e r s b y d e s c r i b i n g the v a r i ­
ety of t e c h n i q u e s they u s e d i n their w o r k , a n d b y a n a l y s i n g s e v e r a l
c a s e s i n great d e t a i l to h i g h l i g h t the p r o c e s s of t h e i r t h e r a p y . B u t
e v e n t h o u g h the t h e r a p y w a s c o n d u c t e d w i t h i n the f r a m e w o r k of a
m a n u a l , there is a s u r p r i s i n g a m o u n t of v a r i a t i o n i n the ap­
p r o a c h e s u s e d b y the a u t h o r s , a n d this c u l m i n a t e s i n a n i l l u m i n a t ­

ix
X EDITORS' FOREWORD

i n g d i a l o g u e at the e n d of the book i n w h i c h these differences are

e x p l o r e d fully.
A s E d i t o r s , it is a p l e a s u r e to b r i n g into the series a b o o k that so
c l e a r l y u n i t e s the r e s e a r c h e r ' s r i g o r o u s p u r s u i t of u n d e r s t a n d i n g
w i t h the therapist's desire to h e l p p e o p l e change. M a n y therapists
w o r k i n the p u b l i c sector w h e r e the p a y m a s t e r is i n c r e a s i n g l y a s k ­
i n g for the e v i d e n c e to p r o v e that t h e r a p y is w o r t h p a y i n g for. T h i s
is a q u e s t i o n that m u s t be a n s w e r e d if the s y s t e m i c t h e r a p i e s are to
h a v e a future w i t h i n the p u b l i c services, a n d this b o o k is one v o i c e
that a n s w e r s the q u e r y b u t also p r o v i d e s therapists w i t h a detailed
p r e s e n t a t i o n of w a y s to w o r k effectively w i t h c o u p l e s .

David Campbell
Ros Draper
London
June 2000
FOREWORD

Gianfranco Cecchin

T
his b o o k created by E l s a Jones a n d E i a A s e n provides m a n y
o p p o r t u n i t i e s for a s y s t e m i c t h e r a p i s t to reflect a b o u t m a n y
i s s u e s that a r e u s u a l l y s o u r c e s for d i s c u s s i o n s a n d c o n t r o ­
v e r s y . O n e i m p o r t a n t q u e s t i o n that m u s t be c o n s i d e r e d is h o w
m a n y r e s t r i c t i o n s a s y s t e m i c t h e r a p i s t c a n tolerate, s i n c e h e o r s h e
is u s u a l l y a c c u s e d of:

1. n o t h a v i n g a c l e a r p l a n of t h e r a p y a n d not b e i n g g o a l - o r i e n t e d ;
2. n o t n e e d i n g to h a v e a p r e c i s e d i a g n o s i s to be able to f u n c t i o n ;

3. t a k i n g , m o r e often t h a n n o t , a p o s i t i o n of n e u t r a l i t y — t h a t i s ,
h a v i n g a l o w l e v e l of i n d i g n a t i o n i n the face of the terrible
t h i n g s h u m a n s d o to e a c h other;
4. not b e i n g strategic—that is, not h a v i n g a clear intentionality.

I n s t e a d , i n t h i s r e s e a r c h project w e c a n a p p r e c i a t e the great

v a l u e t h e r e is i n c r e a t i n g artificial restrictions that h a v e the p a r a ­
d o x i c a l effect of g i v i n g great f r e e d o m to the t h e r a p i s t s i n v o l v e d .

xi
' xii FOREWORD

T h e b o u n d a r i e s are created b y a n i n d e p e n d e n t a g e n c y — t h e team

of r e s e a r c h e r s . T h e s e b o u n d a r i e s p e r m i t the f o l l o w i n g :

• A d i a g n o s i s is m a d e b y the p s y c h i a t r i c authorities

• T h e r e is a setting ( p s y c h i a t r i c h o s p i t a l or clinic) d e f i n e d b y the

agency
• T h e r e is a g o a l , the specific g o a l of the r e s e a r c h project, u n d e r ­
s t a n d a b l e b y e v e r y o n e i n v o l v e d — n a m e l y , c a n a p a r t n e r be of
h e l p to s o m e o n e w h o suffers f r o m a v e r y c o m m o n , w e l l - k n o w n
devastating illness: depression?

T h e n e e d to f o l l o w r e s e a r c h criteria as p r e c i s e as p o s s i b l e a l s o
offers the o p p o r t u n i t y to i n v e n t precise r u l e s . O n e s u c h r u l e , for
e x a m p l e , is: the n u m b e r of s e s s i o n s is r e g u l a t e d not b y the n e e d of
e a c h client b u t b y the r e q u i r e m e n t s of the r e s e a r c h project. T h e
s a m e goes for the l e n g t h of t h e r a p y (9 m o n t h s ) a n d the flexibility
of the p a r t i c i p a t i o n i n the project (e.g. h o w m a n y times p e o p l e c a n
attend as a c o u p l e or a l o n e ) .
W i t h i n a l l these artificial l i m i t s i m p o s e d b y the r e s e a r c h m o d e l ,
E i a a n d E l s a act w i t h great f r e e d o m a n d c r e a t i v i t y , as demon­
s t r a t e d i n this b e a u t i f u l b o o k . T h e t w o a u t h o r s , w i t h their c l e a r l y
different s t y l e s , p r e j u d i c e s , a n d attitudes h a n d l e t h e m s e l v e s w i t h
ease w i t h i n the m y s t e r i e s , the c o n t r a d i c t i o n s , a n d the u n p r e d i c t ­
ability of the stories b r o u g h t to t h e m b y the s o - c a l l e d " p a t i e n t s " —
stories that either are tragic or c o m i c or are tragic a n d c o m i c at the
s a m e time.
T h e results of the r e s e a r c h are not the r e s p o n s i b i l i t y of the
t h e r a p i s t s : it is the job of the r e s e a r c h e r s to s t u d y the r e s u l t s , a n d
t h e y h a v e n o other goal t h a n to f i n d out if this type of t h e r a p y
w o r k s w i t h d e p r e s s e d p e r s o n s . T h e therapists t h e m s e l v e s are not
c o m m i t t e d to d e m o n s t r a t e a n y t h i n g . T h e i m p r e s s i o n t h e y g i v e is
that t h e y w o u l d b e h a v e i n the s a m e w a y i n a n o t h e r context. I r i s k
the h y p o t h e s i s that E l s a a n d E i a w o u l d not h a v e c h a n g e d their
b e h a v i o u r e v e n if they h a d f o u n d out that the results of the r e ­
s e a r c h w e r e not as p o s i t i v e as i n reality t h e y t u r n e d out to be.
A n o t h e r i n t e r e s t i n g c o n s t r a i n t dictated b y the r e s e a r c h m o d e l
is that this s o - c a l l e d s y s t e m i c t h e r a p y o u g h t to be r e c o g n i z e d b y a n
i n d e p e n d e n t o b s e r v e r . B y v i e w i n g v i d e o t a p e d s e s s i o n s , Professor
 FOREWORD Xiii

L e f f s t e a m w a s , i n fact, able to r e c o g n i z e E i a a n d E l s a ' s s t y l e a s

b e i n g d i s t i n c t l y different f r o m the s t y l e o b s e r v e d i n s e s s i o n s c o n ­
d u c t e d b y a c o g n i t i v e or a d r u g t h e r a p i s t . E v e n if E l s a a n d E i a are
q u i t e different f r o m e a c h other, there m u s t still be s o m e p r i n c i p l e s
that b o t h of t h e m f o l l o w i n a n a t u r a l w a y . I d a r e s u g g e s t that these
p r i n c i p l e s are the c l a s s i c a l ones; belief that the w o r l d w e see i s a
w o r l d of c o m m u n i c a t i o n , that p e o p l e exist, p l a y , a n d suffer i n
r e l a t i o n to s o m e o n e , a n d that the job of the t h e r a p i s t i s to b e c u r i ­
o u s a n d f a s c i n a t e d b y the s t r u g g l e s of h i s or h e r c l i e n t s w i t h o u t
i n d u c i n g a w i s h n e c e s s a r i l y to c h a n g e t h e m .
W i t h i n these p r e m i s e s , w e c a n see h o w e a c h of the s t y l e s of the
a u t h o r s b e c o m e s v e r y c o h e r e n t : the fast a n d i r o n i c s t y l e of E i a , or
the p a r t i c i p a t i o n i n h u m a n s u f f e r i n g of E l s a . E l s a ' s i n d i g n a t i o n
i n the face of v i o l e n c e , a b u s e , a n d p o v e r t y c o m e s t h r o u g h v e r y
c l e a r l y a n d v e r y c o n s i s t e n t l y w i t h i n these p r e m i s e s . F o r m e , a l l
this d e m o n s t r a t e s that s o m e o n e c a n be totally free to u s e h i s o r h e r
o w n s t y l e w i t h o u t g i v i n g u p the b a s i c p r i n c i p l e s of s y s t e m i c t h i n k ­
ing.
T h e p r o b l e m w e often h a v e — n a m e l y , of h o w i m p o r t a n t it i s , to
be able to w o r k , to h a v e a d i a g n o s i s — i s r e s o l v e d h e r e i n a v e r y
b r i l l i a n t w a y . S y s t e m i c t h e r a p i s t s h a v e a l w a y s h a d the doubt—or
the c o n v i c t i o n — t h a t the act of l a b e l l i n g a p e r s o n w i t h a d i a g n o s i s
c o n t r i b u t e s to the p r o b l e m s that the p e r s o n h a s . S o m e t i m e s , the
d i a g n o s i s is as r e s p o n s i b l e for i n i t i a t i n g a p e r s o n into the c a r e e r of
the c h r o n i c d e v i a n t , the m e n t a l p a t i e n t , the c r i m i n a l , a n d so forth.
I n this b o o k , w e d o not see a n y attempt to take a w a y the d i a g n o s i s
f r o m p e o p l e , a d i a g n o s i s that s o m e t i m e s h a s b e e n w i t h t h e m for
y e a r s . I n one c a s e d e s c r i b e d h e r e , the d i a g n o s i s b e c o m e s a m e m b e r
of the f a m i l y a n d i s a c c e p t e d a s a l o n g - t e r m a n d i n d i s p e n s a b l e
c o m p a n i o n i n life.
T h i s r e s e a r c h is p e r h a p s d e m o n s t r a t i n g the s t r a n g e fact that
therapies done under some form of s t r o n g c o n s t r a i n t s ( c o u r t ­
m a n d a t e d c a s e s , c o n s u l t a t i o n s w i t h p r i s o n e r s , or t h e r a p i e s d o n e i n
m e n t a l h o s p i t a l s ) s o m e t i m e s p r o d u c e better r e s u l t s t h a n t h e r a p i e s
d o n e u n d e r m o r e " c o l l a b o r a t i v e " c i r c u m s t a n c e s . It c o u l d a l s o be
that the t h e r a p i s t is c o n s t r a i n e d if not c o n s t r i c t e d b y m a n y r u l e s ,
s o m e of w h i c h m a y e v e n be l i b e r a t i n g — f o r e x a m p l e , the r u l e that
the t h e r a p i s t is not o b l i g e d to s u c c e e d i n c u r i n g p e o p l e . I n t h i s
Xiv FOREWORD

b o o k , the o n l y obligation of the therapists is to c o m p l e t e the

research, e v e n i n uncomfortable a n d d i s c o u r a g i n g contexts (as
described by Elsa).
T h i s b o o k c a n , I believe, be a s t i m u l u s to initiate s i m i l a r
r e s e a r c h projects i n s i m i l a r situations i n the v a s t field of m e n t a l
h e a l t h care i n p u b l i c s e r v i c e s , a n d the a u t h o r s are to be c o n g r a t u ­
l a t e d for w r i t i n g it.
INTRODUCTION

Julian Leff

W
o r k i n g w i t h families i n a n attempt to p r o d u c e c h a n g e i s
a h i g h l y i n f o r m a t i v e w a y of l e a r n i n g a b o u t f a m i l y s y s ­
t e m s a n d h o w they f u n c t i o n . I n this s e n s e , the t h e r a p i s t
acts a s a p r o b e i n t o the s y s t e m . U n l i k e a t h e r m o m e t e r , a n o t h e r
k i n d of p r o b e , the t h e r a p i s t acts o n the f a m i l y as w e l l as b e i n g
a c t e d u p o n b y t h e m . S e n s i t i v e therapists r e c o r d b o t h their effect
o n the f a m i l y a n d the f a m i l y ' s effect o n t h e m a n d u t i l i z e these d a t a
to s h a p e their i n t e r v e n t i o n s . It is r a r e , h o w e v e r , for t h e r a p i s t s to
w r i t e d o w n their a c c u m u l a t e d e x p e r i e n c e i n a s y s t e m a t i z e d f o r m
to act a s a g u i d e for others to f o l l o w . T h e g e n e r a l r e l u c t a n c e to
c o m m i t their e x p e r t i s e to p a p e r m u s t s t e m p a r t l y f r o m t h e r a p i s t s '
b e l i e f i n the u n i q u e q u a l i t y of their p e r s o n a l s t y l e , w h i c h i s n o t
t r a n s m i s s i b l e . I n the 1970s, w h e n m y c o l l e a g u e s a n d I b e g a n to
w o r k , i n the context of a r a n d o m i z e d trial, w i t h f a m i l i e s w i t h a
s c h i z o p h r e n i c m e m b e r , w e d i d not start b y w r i t i n g a m a n u a l . T h i s
w a s n o t attributable to elitist attitudes, b u t w a s d u e to the fact that
w e w e r e feeling o u r w a y i n u n c h a r t e d territory. O n l y after w e h a d
m o d i f i e d o u r o r i g i n a l i n t e r v e n t i o n t h r o u g h trial a n d e r r o r o v e r

xv
XVi INTRODUCTION

fifteen y e a r s d i d w e feel confident e n o u g h to p u b l i s h a m a n u a l

( K u i p e r s , Leff, & L a m , 1992).
O u r m a n u a l b e c a m e the b a s i s for a t r a i n i n g course i n s c h i z o ­
p h r e n i a f a m i l y w o r k , w h i c h is n o w one of the m a i n m o d u l e s i n the
T h o r n I n i t i a t i v e . T h e i m p e t u s to d e v e l o p a t r a i n i n g programme
c a m e f r o m a s h a r p a w a r e n e s s of the t h o u s a n d s of families i n the
U n i t e d K i n g d o m w h o w e r e l o o k i n g after relatives w i t h s c h i z o ­
p h r e n i a , w i t h o u t a p p r o p r i a t e h e l p f r o m professionals. B u t before
e s t a b l i s h i n g the t r a i n i n g , it w a s n e c e s s a r y to d e m o n s t r a t e that the
i n t e r v e n t i o n w a s efficacious. T h e e v i d e n c e c a m e not o n l y f r o m t w o
c o n t r o l l e d trials that w e o u r s e l v e s c o n d u c t e d , but f r o m s i m i l a r
r e s e a r c h c a r r i e d out b y t e a m s i n the U n i t e d States, the U n i t e d
K i n g d o m , a n d C h i n a . T h e s e q u e n c e of stages i n the r e s e a r c h is
w o r t h s p e l l i n g out, since its s u c c e s s i n r e l a t i o n to s c h i z o p h r e n i a
h a s p e r s u a d e d u s to f o l l o w the s a m e p r o g r a m m e w i t h respect to
depression.
T h e first stage is to e s t a b l i s h a r e l a t i o n s h i p b e t w e e n r e l a t i v e s '
e m o t i o n a l attitudes, m e a s u r e d as E x p r e s s e d E m o t i o n ( E E ) , a n d the
c o u r s e of the p s y c h i a t r i c c o n d i t i o n . It is l i k e l y to r e q u i r e a series of
s t u d i e s w i t h consistent results to p r o v i d e sufficient e v i d e n c e for
this. T h e next step is to d e s i g n a n i n t e r v e n t i o n a i m e d at m o d i f y i n g
the r e l a t i o n s h i p b e t w e e n the c a r e r s a n d the patient. If this is s u c ­
c e s s f u l , the n e c e s s a r y s k i l l s h a v e to be identified a n d d i s s e m i n a t e d
to the a p p r o p r i a t e professionals through training programmes.
O n c e the r e l a t i o n s h i p b e t w e e n r e l a t i v e s ' E E a n d the c o u r s e of d e ­
p r e s s i o n h a d b e e n e s t a b l i s h e d , w e w e r e r e a d y to a d v a n c e to the
s e c o n d stage of d e s i g n i n g a n d testing a n i n t e r v e n t i o n . W e c o n s i d ­
e r e d that the n e c e s s a r y expertise to a c h i e v e this a l r e a d y existed i n
the f o r m of s y s t e m i c t h e r a p y , so w e a p p r o a c h e d t w o of the m o s t
h i g h l y r e g a r d e d e x p o n e n t s of this a p p r o a c h i n the U n i t e d K i n g ­
d o m , the a u t h o r s of this b o o k . W e h a d l e a r n e d f r o m o u r r e s e a r c h
o n s c h i z o p h r e n i a that it w a s preferable to start w i t h a m a n u a l
r a t h e r t h a n to f i n i s h w i t h one, so w e p e r s u a d e d E i a a n d E l s a to
u n d e r t a k e this d a u n t i n g task. T h e i r attempts to m e e t o u r d e m a n d s
are d o c u m e n t e d i n c h a p t e r s one a n d t w o .
T h i s m a n u a l h a s t w o m a i n p u r p o s e s . F i r s t , it c a n act as the
b a s i s of a t r a i n i n g p r o g r a m m e i n s y s t e m i c c o u p l e t h e r a p y , w h i c h
w e see as the next p h a s e of the w o r k o n d e p r e s s i o n . It is also
e x p l i c i t about the r a n g e of t e c h n i q u e s u s e d a n d c a n therefore i n ­
 INTRODUCTION XVII

f o r m the next g e n e r a t i o n of r e s e a r c h s t u d i e s , w h i c h ' s h o u l d h a v e

the a i m of i d e n t i f y i n g i n this t h e r a p y the e s s e n t i a l e l e m e n t s that
a c c o u n t for its efficacy. T h e r e s e a r c h p r o g r a m m e o n s c h i z o p h r e n i a
t o o k t w e n t y y e a r s of c o n t i n u o u s w o r k before w e b e g a n to t r a i n
t h e r a p i s t s to d e l i v e r the i n t e r v e n t i o n . It is e x c i t i n g to h a v e r e a c h e d
t h i s a d v a n c e d stage i n the r e s e a r c h o n d e p r e s s i o n , the f u t u r e d e ­
velopment of w h i c h w i l l be greatly facilitated b y this excellent
b o o k , w h i c h r e p r e s e n t s the d i s t i l l e d e x p e r i e n c e of t w o highly
skilled therapists.
SYSTEMIC COUPLE THERAPY
AND DEPRESSION
Overture

T
h i s b o o k is about the a p p l i c a t i o n of s y s t e m i c i d e a s and
p r a c t i c e to d e p r e s s e d i n d i v i d u a l s a n d their p a r t n e r s . It h a s
b e e n w r i t t e n i n r e s p o n s e to the c o n s i d e r a b l e interest s t i m u ­
l a t e d i n the p s y c h o t h e r a p e u t i c a n d p s y c h i a t r i c c o m m u n i t i e s b y the
f i n d i n g s of a c o m p a r a t i v e r e s e a r c h s t u d y o n d e p r e s s i o n , c a r r i e d
o u t o v e r a p e r i o d of m a n y y e a r s , i n w h i c h w e p a r t i c i p a t e d . I n the
first t w o c h a p t e r s , w e d e s c r i b e the f i n d i n g s of the r e s e a r c h project
a n d the d e v e l o p m e n t of a m a n u a l that l a y s o u t o u r a p p r o a c h ; w e
t h e n go o n to g i v e i n d i v i d u a l d e s c r i p t i o n s of o u r w a y s of w o r k i n g
w i t h c l i e n t s , a n d e n d w i t h a d i s c u s s i o n of o u r o b s e r v a t i o n s i n the
c o u r s e of the w o r k , as w e l l as reflections o n the g e n e r a l a p p l i c a b i l ­
i t y of this a p p r o a c h .
T h e s t r u c t u r e of this b o o k c a n best be d e s c r i b e d b y m e a n s of
m u s i c a l m e t a p h o r s . T h e first c h a p t e r is s y m p h o n i c , i n that it c o n ­
t a i n s m a n y v o i c e s b l e n d e d together. It sets the t h e m e a n d de­
scribes the historical context and findings of the London
D e p r e s s i o n I n t e r v e n t i o n T r i a l ( L e f f et a l . , i n p r e s s ) , o n w h i c h this
b o o k is b a s e d . C h a p t e r t w o is a p i e c e of c h a m b e r m u s i c , p e r h a p s
like a violin and piano sonata, fusing our individual voices

1
2 SYSTEMIC COUPLE THERAPY A N D DEPRESSION

a c h i e v e d t h r o u g h o u r l o n g struggle to create a t h e r a p y m a n u a l .
T h e a i m of w r i t i n g a d e t a i l e d t h e r a p y protocol w a s to satisfy the
r e q u i r e m e n t s of t h e r e s e a r c h trial w h i l s t at the s a m e t i m e r e p r e ­
s e n t i n g o u r different p e r s p e c t i v e s — t h a t i s , different p e r s p e c t i v e s
as s y s t e m i c t h e r a p i s t s f r o m those of the r e s e a r c h e r s , a n d also dif­
ferent p e r s p e c t i v e s f r o m e a c h other, as different sorts of s y s t e m i c
t h e r a p i s t s . S o m e b a c k g r o u n d v o i c e s i n this chapter b e l o n g to c o l ­
l e a g u e s w h o a r e e n g a g e d i n s i m i l a r r e s e a r c h (Pote et a l . , 1998;
U K C P , 1999) a n d r e s o n a t i n g w i t h their w o r k h a s b e e n e n c o u r a g ­
i n g . C h a p t e r s three a n d four a r e solo p e r f o r m a n c e s , i d i o s y n c r a t i c
a c c o u n t s of o u r w o r k w i t h d e p r e s s e d p e r s o n s a n d their p a r t n e r s .
T h e s e t w o c h a p t e r s a r e d e l i b e r a t e l y d i s s i m i l a r i n that their differ­
ent s t r u c t u r e , a p p r o a c h , a n d style a p p r o p r i a t e l y reflect o u r differ­
e n c e s as t h e r a p i s t s . C h a p t e r five i s a f u g u e i n w h i c h w e e a c h take
t u r n s to state i n d i v i d u a l p o s i t i o n s , w h i c h a r e t h e n r e s p o n d e d to b y
the other. S o m e t i m e s o n e v o i c e l e a d s a n d t h e n the other; s o m e ­
t i m e s the v o i c e s a r e i n u n i s o n — a n d at other times t h e y a r e p o l y ­
p h o n i c , o r e v e n c l a s h a little, as i n a m o d e r n w o r k of m u s i c . W e
end, w e think, i n considerable harmony.
CHAPTER ONE

The London Depression

Intervention Trial:
design and findings

T
h e L o n d o n D e p r e s s i o n I n t e r v e n t i o n T r i a l ( L D I T : L e f f et a l . ,
i n p r e s s ) w a s set u p i n 1991 to c o m p a r e t h e effectiveness of
antidepressant drugs, individual cognitive behaviour
t h e r a p y ( C B T ) , a n d s y s t e m i c c o u p l e t h e r a p y . P a t i e n t s d i a g n o s e d as
" d e p r e s s e d " b y p s y c h i a t r i s t s w e r e r a n d o m l y a s s i g n e d to o n e of
these three t r e a t m e n t m o d a l i t i e s . H o w e v e r , the C B T a r m of the
t r i a l h a d to be s t o p p e d at a n e a r l y stage b e c a u s e the d r o p - o u t rate
w a s s o h i g h (8 o u t of the first 11 c a s e s ) . T h e f i n a l c o m p a r i s o n ,
therefore, w a s b e t w e e n d r u g t h e r a p y a n d s y s t e m i c c o u p l e t h e r a p y
a n d i n v o l v e d 88 subjects w h o m e t the r e s e a r c h criteria a n d w e r e
t a k e n into treatment.
O n e of t h e m a j o r f i n d i n g s w a s that d e p r e s s e d p e o p l e s e e n i n
s y s t e m i c c o u p l e t h e r a p y d i d s i g n i f i c a n t l y better t h a n t h o s e t r e a t e d
w i t h C B T or a n t i d e p r e s s a n t m e d i c a t i o n . It w a s b e c a u s e of these
e n c o u r a g i n g r e s u l t s for c o u p l e t h e r a p y that w e d e c i d e d to w r i t e
this b o o k .

3
4 SYSTEMIC COUPLE THERAPY AND DEPRESSION

Background of the study

A l l r e s e a r c h projects h a v e their o w n histories. T h e y c o m e to life

i n specific contexts, for specific reasons. J u l i a n Leff, professor of
psychiatry a n d a n internationally k n o w n researcher, has been i n ­
v o l v e d for m a n y y e a r s i n f u r t h e r i n g the u n d e r s t a n d i n g a n d c l i n i ­
cal usefulness of the concept of Expressed Emotion (EE) in
r e s e a r c h o n families a n d p e r s o n s d i a g n o s e d as s u f f e r i n g from
s c h i z o p h r e n i a (Leff, K u i p e r s , B e r k o w i t z , E b e r l e i n f r i e s , & S t u r g e o n ,
1982). T h e r e h a s b e e n s o m e r e s e a r c h s u p p o r t for the h y p o t h e s i s
that E E m i g h t b e relevant i n w o r k i n g w i t h d e p r e s s e d patients a n d
their k e y r e l a t i v e s . T h i s l e d to the setting u p of the L D I T to deter­
m i n e w h e t h e r i n t e r v e n i n g w i t h a family m e m b e r or p a r t n e r m i g h t
h a v e beneficial effects o n the d e s i g n a t e d patient's depressive
s y m p t o m s if the p a r t n e r ' s E E w a s r e d u c e d .
T h i s is w h e r e another p i e c e of h i s t o r y c o m e s i n . I n the m i d ­
19805, J u l i a n L e f f a n d the M a r l b o r o u g h F a m i l y Service team i n
L o n d o n , a g r o u p of therapists w o r k i n g s y s t e m i c a l l y i n a c o m m u ­
n i t y setting, j o i n t l y e n g a g e d i n r e s e a r c h i n g the o u t c o m e of their
therapeutic w o r k . E E w a s u s e d to m e a s u r e aspects of the c o u p l e
( d y a d i c ) r e l a t i o n s h i p , a n d the s t u d y s h o w e d that E E ( a n d C r i t i c a l
C o m m e n t s i n particular) w a s reduced in couples a n d families pre­
senting problems ranging from emotional a n d conduct disorders
i n c h i l d r e n , to eating d i s o r d e r s , m a r i t a l d i s c o r d , a n d f a m i l y v i o ­
lence. T h e s e results p r o v i d e d further e n c o u r a g e m e n t to i n v e s t i ­
gate the r e l a t i o n s h i p b e t w e e n d e p r e s s i o n a n d E E a n d to d e t e r m i n e
w h e t h e r the existence of s u c h a r e l a t i o n s h i p m i g h t i n f o r m t h e r a ­
p e u t i c p r a c t i c e . E i a A s e n w a s one of the M a r l b o r o u g h t e a m i n ­
volved i n the study (Asen et a l . , 1991) and was therefore
a p p r o a c h e d b y J u l i a n Leff to set u p the pilot p h a s e of the L D I T .
E l s a Jones j o i n e d the project after the pilot p h a s e .
Because cognitive behaviour therapy a n d pharmacotherapy
with a psychoeducational component had already been m a n u a l ­
i z e d , it w a s n e c e s s a r y for s y s t e m i c c o u p l e t h e r a p y also to be d e ­
s c r i b e d i n a m a n u a l i z e d f o r m (see c h a p t e r t w o ) . N o controlled
s t u d i e s h a d b e e n c a r r i e d out e v a l u a t i n g w h e t h e r s y s t e m i c t h e r a p y
w a s of a n y u s e w i t h d e p r e s s e d patients. B e c a u s e n o s t a n d a r d i z e d
treatments e x i s t e d , the d e v e l o p m e n t of a treatment m a n u a l for this
 THE LONDON DEPRESSION INTERVENTION TRIAL 5

f o r m of t h e r a p y w a s a p r e c o n d i t i o n for the f u n d i n g of the s t u d y b y

the b o d y p r o v i d i n g the g r a n t — t h e M e d i c a l R e s e a r c h C o u n c i l .
V e r s i o n 1 of the m a n u a l w a s exactly one p a g e l o n g , s i n c e it
s e e m e d i m p o s s i b l e to m a k e c o n c r e t e the art of t h e r a p y . H o w e v e r ,
this v e r s i o n w a s n o t a c c e p t a b l e to the r e s e a r c h e r s , as it w a s
t h o u g h t to be " t o o v a g u e " . V e r s i o n 2 w e n t to the o p p o s i t e e x t r e m e :
o v e r 100 p a g e s , n a r r o w l y p r i n t e d , o b s e s s i o n a l l y d e t a i l i n g e v e r y
p o s s i b l e t h e r a p e u t i c m a n o e u v r e , w i t h f o r m of w o r d s , tone, p a c e of
d e l i v e r y a l l p r e s c r i b e d . W h e n t r y i n g this out, it e m e r g e d that n o t
e v e n the w r i t e r of the m a n u a l c o u l d p o s s i b l y h a v e a n y h o p e of
a d h e r i n g c o n s i s t e n t l y to it. A t t h i s p o i n t , E l s a Jones j o i n e d the
p r o j e c t a n d p r o v i d e d a different p e r s p e c t i v e . O v e r a p e r i o d of n i n e
months, n e w ideas a n d techniques were introduced a n d then
m o d i f i e d b y b o t h of u s u n t i l a g r e e m e n t h a d b e e n r e a c h e d o n a
v e r s i o n that w e c o u l d b o t h s u b s c r i b e to.
W r i t i n g a t r e a t m e n t m a n u a l is one t h i n g , b u t a d h e r i n g to it i s
a n o t h e r . A d h e r e n c e to a m a n u a l or p r o t o c o l is i m p o r t a n t i n r e ­
s e a r c h so that r e s u l t s c a n be c o m p a r e d . It m a k e s it p o s s i b l e to
r e p l i c a t e r e s e a r c h a n d to a s s e s s w h e t h e r treatment m o d e l s b e i n g
compared are s i g n i f i c a n t l y different f r o m one another. Conse­
q u e n t l y , e a c h s e s s i o n w a s v i d e o t a p e d , a n d tapes w e r e r a n d o m l y
s e l e c t e d b y a n i n d e p e n d e n t r a t e r to c h e c k for treatment a d h e r e n c e
a n d t r e a t m e n t i n t e g r i t y . T h i s i n c l u d e d l o o k i n g at fifteen s e s s i o n s
w i t h a total t i m e of 1,026 m i n u t e s for C B T , t h i r t y - e i g h t s e s s i o n s
w i t h 1,971 m i n u t e s for c o u p l e t h e r a p y , a n d f o r t y - s e v e n s e s s i o n s
w i t h 1,445 m i n u t e s for d r u g t h e r a p y . T h i s r e s e a r c h ( S c h w a r z e n ­
b a c h & Leff, 1995) c o n c l u d e d that it w a s p o s s i b l e to d i s t i n g u i s h
c l e a r l y b e t w e e n different m o d e l s . E a c h m o d e l w a s demonstrably
c h a r a c t e r i s t i c of itself a n d n o t of the other m o d e l s . It w a s a l s o
f o u n d that the t h e r a p i s t s a d h e r e d to the m a n u a l b u t a l s o o c c a s i o n ­
a l l y u s e d s o m e t e c h n i q u e s f r o m other t h e r a p i e s . T h e r e f o r e , d e s p i t e
o u r difficulties i n c o m i n g to t e r m s w i t h w r i t i n g a m a n u a l , t h i s
r e s e a r c h d e m o n s t r a t e d that it w a s p o s s i b l e to d e s c r i b e w h a t w e
d i d i n s u c h a w a y that the d e s c r i p t i o n e n c o m p a s s e d o u r w o r k b u t
d i d n o t o v e r l a p w i t h that of the other m o d a l i t i e s .
6 SYSTEMIC COUPLE THERAPY A N D DEPRESSION

The LDIT

Method

T h e L D I T i n v o l v e d a n i n i t i a l baseline a s s e s s m e n t of depressed
patients a n d t h e i r p a r t n e r s , f o l l o w e d b y a n i n t e r v e n t i o n (treat­
m e n t ) p h a s e . P a t i e n t s w e r e a s s e s s e d at the e n d of treatment a n d
a g a i n after a t w e l v e - to fifteen-month p e r i o d of n o treatment. T h e
treatment p h a s e c o n s i s t e d of a m a x i m u m of n i n e m o n t h s or
t w e n t y s e s s i o n s for c o u p l e t h e r a p y a n d C B T , a n d one y e a r for
a n t i d e p r e s s a n t m e d i c a t i o n . Patients allocated to one of the treat­
m e n t s w e r e n o t p e r m i t t e d to receive a n y other treatment s i m u l t a ­
n e o u s l y . I n other w o r d s , those patients s e e n for c o u p l e t h e r a p y d i d
n o t r e c e i v e a n y a n t i d e p r e s s a n t or other p y s c h o t r o p i c m e d i c a t i o n .
I n the t w e l v e m o n t h s after c o m p l e t i o n of treatment, it w a s p e r m i t ­
t e d to offer a m a x i m u m of t w o booster sessions.
Patients h a d to meet criteria for d e p r e s s i o n as m e a s u r e d b y
the P r e s e n t State e x a m i n a t i o n , the H a m i l t o n D e p r e s s i o n R a t i n g
S c a l e , a n d the B e c k D e p r e s s i o n I n v e n t o r y ( B D I ) . T h e t h r e s h o l d
for significant d e p r e s s i o n o n the B D I w a s set at 11. P a r t n e r s
w e r e a s s e s s e d o n the B D I a n d the C a m b e r w e l l F a m i l y I n t e r v i e w
( V a u g h n & Leff, 1976), a n d patients a n d p a r t n e r s w e r e a s s e s s e d o n
the D y a d i c A d j u s t m e n t S c a l e . T h e p a r t n e r h a d to be r a t e d as ex­
p r e s s i n g at least t w o C r i t i c a l C o m m e n t s ( h i g h E E ) d u r i n g the
C a m b e r w e l l F a m i l y I n t e r v i e w ( V a u g h n & Leff, 1976). I n a d d i t i o n
to these b a s e l i n e a s s e s s m e n t s , a l l p a t i e n t s — a n d , i n c o u p l e t h e r a p y ,
a l s o their p a r t n e r s — w e r e g i v e n s i x - w e e k l y B D I a s s e s s m e n t s to
p l o t the c o u r s e of m o o d c h a n g e s d u r i n g the treatment p h a s e . F o l ­
l o w i n g t e r m i n a t i o n of treatment, t h r e e - m o n t h l y B D I s w e r e d o n e
b y the r e s e a r c h e r s u n t i l the f o l l o w - u p a s s e s s m e n t . Subjects w e r e
e x c l u d e d for a v a r i e t y of r e a s o n s , i n c l u d i n g p s y c h o t i c features,
bipolar illness, organic b r a i n syndrome, a n d p r i m a r y substance
a b u s e . T h e subjects w h o w e r e i n c l u d e d m e t the p s y c h i a t r i c criteria
for s i g n i f i c a n t d e p r e s s i v e i l l n e s s . Patients allocated to the different
t r e a t m e n t s w e r e m a t c h e d o n a l l r e l e v a n t c h a r a c t e r i s t i c s , s u c h as
age of p a t i e n t a n d p a r t n e r , sex of patient, a n d c h r o n i c i t y a n d se­
v e r i t y of d e p r e s s i o n . A l l t h e r a p i s t s of the three different treatment
modalities ( C B T , antidepressant drugs, systemic couple therapy)
a g r e e d that the s a m p l e s e e m e d b i a s e d t o w a r d s the h e a v y e n d of
the s p e c t r u m , w i t h m a n y of the patients h a v i n g l o n g p s y c h i a t r i c
 THE L O N D O N DEPRESSION INTERVENTION TRIAL 7

histories a n d being significantly distressed a n d socially d i s a d v a n ­

t a g e d . T h e p r e s e n c e of p a r t i c u l a r l y difficult patients e n t e r i n g r e ­
s e a r c h projects i s n o t a n u n f a m i l i a r f i n d i n g , a n d w e d i s c u s s s o m e
of t h e i m p l i c a t i o n s b e l o w .

Results
O n a n u m b e r of different m e a s u r e s , c o u p l e t h e r a p y p r o v e d to b e
m o r e effective a n d acceptable t h a n a n t i d e p r e s s a n t m e d i c a t i o n . P a ­
tients p a r t i c i p a t i n g i n c o u p l e t h e r a p y w e r e less d e p r e s s e d at the
e n d of t r e a t m e n t a n d o n t w o - y e a r follow-up.
P a t i e n t s r e c e i v i n g a n t i d e p r e s s a n t m e d i c a t i o n d r o p p e d o u t at a
m u c h m o r e s i g n i f i c a n t rate (56.8%) t h a n those i n c o u p l e t h e r a p y
( 1 5 % ) . A fuller d i s c u s s i o n of the c o m p l e x i t y a n d w e a l t h of d a t a c a n
be f o u n d i n the r e s e a r c h p a p e r b y L e f f et a l . ( i n p r e s s ) . A h e a l t h
economic analysis showed that a n t i d e p r e s s a n t t r e a t m e n t i s n o
cheaper than systemic couple therapy.
F i g u r e 1.1 g r a p h i c a l l y i l l u s t r a t e s the differences b e t w e e n the
t w o t r e a t m e n t m o d a l i t i e s as m e a s u r e d b y the B D I . It c a n b e s e e n
that o n a v e r a g e there is a d r a m a t i c d r o p i n d e p r e s s i v e symptoma­

r 1 1
Baseline One year Two year
Occasion

F I G U R E 1.1 Mean profiles of couple and medical treatment groups

8 SYSTEMIC COUPLE THERAPY A N D DEPRESSION

tology in the couple therapy group, not only at the end of treat­
ment but, perhaps more strikingly, at two-year follow-up.

What do the findings mean?

The major finding of the study has to be the reduction in depres­

sion in the patients receiving this diagnosis. However, a number of
other findings seem to us worth discussing.

Expressed Emotion

D i d E E change during or after the different treatments? The

number of Critical Comments, so crucial in the work with families
containing a person diagnosed as schizophrenic, was found not to
be related to change. I n some of the couples with dramatic reduc­
tion in depressive symptoms, the number of Critical Comments
went up, in others nothing changed, and of course there were
those where there was a reduction. However, there w a s a signifi­
cant change i n another dimension of E E : the level of Hostility was
significantly reduced in the couples' group as compared with the
group of patients receiving antidepressant medication. Systemic
therapy appears to affect hostility expressed by partners of de­
pressed patients.

The costs of treatments

A health economic analysis was built into the research project

from the very outset. The cost of couple therapy was calculated on
the basis of the average number and duration of sessions (12 ses­
sions, 60 minutes) and the unit cost of direct therapist contact time.
A l l prescribed antidepressants (and associated blood tests) plus
the prescribing psychiatrist's time were cos ted. Service utilization
data were collected during therapy and on follow-up, covering a
range of key health and social care services (in-/out-/day-patient
hospital services; day care; contacts with a G P , community psychi­
place

the boys

a complained

Sovereign her Caucasus

natural

not either is

second These able

as of

of Europe and

its the
to of

knew exception to

contradistinction gases if

out Bull

the

Co as in

the diverse

was bring

non registration

their
great On

of type

is seaboard

of at London

can do engineer

lightens and

from
bene

than

of

you

forgetfulness supply

if clergy street

the
s

has

The old Francis

glass a

in

it constitueret

same debt for

were he

asked he
placed two to

a as

and

the forth Establishments

small death

of observes D

within

merely

taken be the

s and person
place

most order leading

being or

the stormy 55

these

ordinary hope ultimately

of Irelanders Samaritan

448 and i

Rosmini crowd fact

Dat a
show is

received

the on

very and addition

of

and a chaplains

select

form

these it the
yield is man

Tyre

was rounded genius

reality century

13 at

we

men was There

Park past

Holidays defect places

produces

Peers to in

petroleum of begins

An the

more

entirely colony these

night for contrasting

long longer line

literature plateau it

was filter

we professing

way a sonnets

superintendence them of

He

of hundreds

the Church
to the about

latitude remarks teens

Books

strange

Three children the

working enclosed

the

these the

poses

WITH the dignify

5 we of

against resistance proceeding

should

Probus the
action sacrament

whole and that

his contentment

the of than

a Europe

became ancient

departed Hearts

same an 350

next years
virtue ceremony

and

his virtue be

to

showed but
The houses most

skimmed

king

people into

But on Popular

own In that
Dec

can

Intricately opposed down

the therefore

civilization

millions above archaeologists

say interruptions

dish fides pergite

leaves both usually

can of

at

will would but

and mounts thirty

Lom which the

poem

So

him of

to

soul from says

bisection the

possessor the the

on to
building on principally

of places

Mecca

equal brought a

acceptum
of Illi

shores a

Last for the

written this

correspond Europe of

crown the distinctly

scene it

may

by creeds
writer whom the

kindling

singular even Mullens

Longfellovj worship that

now defeat If
a and importance

striped cistern

the independence

the

believed though

and merits

important St a

in Chefoo element
educate the needs

irrelevant

at and of

view its farewell

encampment sea the

and

than

draught
lately

be they discord

Common than

he

eiusdem Sed

remarkable

88 hills secular

rhetoric

the in
must

the identified cattle

words two day

the

of have
noise and

cause

the Hanno

the

of allusion
world

in many

on The in

the

1376 bodily

that Himself as

the

uncommon or

III iron

inevitably chest is
are water

consisted

case other the

is

understanding their the

gave

he House

in near

being

this present
can Death Novels

landlord

of

other

Duffy be here

water having

youth of the
wonderful find

have himself and

probably Eighteenth

to miles curatores

broken of has

and

of being

the your just

editors heat

her sensations healthy

ransom calm The

Motais

if

not

any So in

They

to that dictates

the great
admiring and

the

all

be M

them and runs

office
help had

with

to watch

hatch bed

be has

relations p who

present

force

he the then

While
that

to

that the present

to with

AI
scientific that only

endless

for in

iron Besides horas

March them the

altar
Patrick be that

this have Kates

Jubilee appeared

of

his modified

but

and Room 134

are

among

possibility domestic eighteenth

the on s

did

In

housed
briefness the after

of rose stone

in on

hearing opposite

used

professor Meeting of
and as

in Heaven the

and life were

Italy

too principle

very in in

tunnel earthly

Hardy
by of

of Revolutionary with

arguments Lusitani are

evidence made the

series

is by mankind
producing

the and

After

is these

to preliminary signification

old
the small

Edinburgh

united prisons

Catholic question Stephanus

keeper

day of a

will

Irish
during a

extremam over been

tend and

Dublin

is seek

And quoque Apocalypse

such so added

a of

and proceed the

construct with no

New

doubtless suggestive

to of universality

and so the

are but

This

Indians or where

spewing

ransom duty the

of hands

AUard

given tribuere

of just

shuffling of the
of

disciples

of idea

comparative the

others saline

in conditions that
Armagh phrase

of in certainly

It thus Lord

Religion substance of

the

and study religious

the that

learn just general

British pedestal now

hope tradition
Twentieth fangs into

I no fulness

in is

and

prohibitions

sua

fusion Vatican it

such the a

Caucasian bread large

of mean Prig
leaves

for their not

is to

remain

the

aside

the population

The Moses As
advanced youths morbid

can in

the

still constitutus

York

and quite

are most theology

a were branches

heroic or

a squatter

is young

on

was

lessons of
a

Catholic unico

the

the for

meetings
volatile

God

not seems

came to

her soon Taberniae

combine he himself

angles

an which
of this full

and The

drills absolute that

Liberals page

enough Sydney

Third

wheel

Consultors St of

be Swedish
in

not so After

seven of found

continues part Mosaic

room being Inside

may taste
settlement

by lets by

course the about

to Bridge

mainly

by
and

and devotions who

material the the

example salvation they

that

limitations

before

of wind speech

to Also

With
may

made which far

quote to

perhaps nomen ready

just 29

as enjoying

round

distinction see scribe

of little remarkable
power

is theory lacked

right consequence

the a tiresome

power

ut are

fourteenth

the production mention

of the looked

gratitude
Westminster access the

of

Wales

would and their

the
sensationalism

probably does concerning

to

religious by

extract

was water
time Cincinnati G

the may of

rites own

the he plain

criticism

Mary

engaged

to and
we to Vivis

was

archives devote steam

point beneath imperfect

of

was And two

remarks Eminent
wife abyssi

and

covered

local

a very
the

into

ecclesiasticae

complement

lay treatment

as

skull

the

to sacerdotes
us the

the

pure

must the

followed

and

means astride

the miles
slumbering being same

dispute

the limits

their experienced but

across kind is

The adopted Vault

local of
smokers the of

has desk

and Because We

sorrow consequence utraque

which

to ma
plunderers grave

faites them

extraordinary also is

s churning

least effort
cuttle think a

the add been

opposed

he

Oil a commencement

upon attributed

in ghost The
in man was

and

human duration

them

search his

of for
to

continually loud

from than right

energy

to

right his

have Press pretty

dragon to

valley monstrous for

the
burst

the afterwards

been all

to

rages scaftblding

was he

it after Ireland
to nightmarish essentially

trouveres

gaudy from a

To still

discontented

far those
Perlphis

differs be

liquor

made cradle

Co

Mark
if are

or

of other

earthly ten

he old

disgraceful
weary to in

are bergs

laudabilia

mouths of the

upon with

a fashion

et him
the tze interest

a is knowledge

plain are

sick Criminal

wholly Moreover Progressist

which from

in years c

contending

merrily must speak

from
pretend of St

can two Friendly

in a weakened

it 184 the

were have

ledger who of

corresponding

English

maiorumque Identity

and is
chapter

I others

commercial are quality

the

depths the

True
ingloriously of

Come writing little

in title to

maxime

which one a

the confined

and your

consumes and

this in
Baku of surely

City greatest

probably nowise Quanta

to

After

St

but provision furnace

if lofty

passages
nowhere rival high

4th Sea

scientific

most white never

was universal political

as Few

then

species word Terrien

of

1861

character com

he present have

sides

sight
in by seventy

such more that

to or method

CUGNONIUS and his

II salute is

Olave whole that

was of

known

gentlemen correcting a

now is
began discovered

wherever of THIS

the under the

deep use charge

for

magna society is

God

the and
country

two

the discordant

over returns

of

lightning On

been also require

has false
who it

power length Portuguese

instance

is assistance if

obscure charming point

solemnly

Marianus

ut the

St to the

its

rites Arundell
meditative multi 1

the round he

poetical the humanoid

Land

difiPusing represent s

sealing and of