Relationship Difficulties: The aspects of loneliness, breakdowns and bereavement.

Loneliness, breakdowns, and grief are profound experiences that can significantly impact a person's emotional and mental well-being. These aspects can intertwine, affecting one's overall mood and outlook. Recognising the signs and seeking help or support when needed is vital. Addressing these feelings can lead to healing and a more profound understanding of oneself and one's needs. 

Introduction.

Relationships are essential, as they are a source of joy, comfort, and meaning. For this reason, difficulties can have significant impacts and are critical to consider in the context of mental health. For this reason, this Blog will explore arguments that relationship and intimacy issues are substantial reasons why people feel distressed and consequently seek therapy - relationship issues ignored in mental health settings. For example, psychiatric diagnoses, such as depression, are applied to individuals and are thought to be illnesses. 

Understanding Relationship Difficulties.

The focus is on meaningful emotional relationships with family, romantic partners, and friends. The person with whom we have such a relationship can be positive, negative, or very mixed, but this person certainly matters.

Difficulties in relationships can occur in many ways; however, some of the most common groups are loneliness, relationship conflict and breakdowns, abusive relationships and grief.

Acknowledging that what has been abusive varies across places and times. For example, in the UK, it was not a crime for a man to rape his wife until 1991 (R v R, 1991). The practice of female genital mutilation is a cultural practice in some parts of the world, but in Britain, it is illegal and defined as child abuse (Female et al. Act 2003). 

Understanding that relationship difficulties can associated with culture is essential because they reflect current social, political, and legal understandings. 

Difficulties with sexual relationships.

What might constitute relationship difficulties that lead a person to seek counselling; this topic itself has concerned mental health practitioners, as seen in many diagnoses around sex. 

Sexual concerns are not uncommon in society (McCabe et al., 2016), and they may be becoming more familiar with reported increases in sexual dysfunction in young men (Park et al., 2016). Suggested that difficulties in sexual relationships can be highly distressing and negatively impact the quality of life; the diagnosis of sexual dysfunction is not uncontroversial. 

It is assumed in diagnoses that certain types of sexual response are standard and certain types are abnormal. For example, male sexual desire and female arousal disorder are both thought to be a problem to treat if someone does not feel sexual and is distressed by it. However, there is currently no accepted understanding of what constitutes a normal and abnormal sexual response. 

The International Classification of Diseases (ICD-11) includes the new diagnosis of 'compulsive sexual behaviour disorder' (World Health Organization (WHO), 2018); in DSM-5, there is no corresponding diagnosis for someone worried about being overly sexual. 

Placing problems of premature ejaculation within a male-female sexual relationship and restricting it to penis-in-vagina sex. The definition ignores non-heterosexual partners and prioritises penis-in-vagina sex as the most important thing. The diagnosis potentially only reflects and reinforces current and heteronormative social understandings of sex. 

Sexual stamina in men is considered highly prized (Vares & Braun, 2006), whilst in Britain, a minority of the male population uses medication to enhance sexual performance (Mitchell et al., 2016). Not to belittle any distress that men may naturally feel about premature ejaculation. Questioning whether the diagnosis of premature ejaculation is unhelpfully reinforcing pressure on men to perform sexually. 

What are the impacts of relationship difficulties? 

Relationship difficulties negatively impact people, which might bring them to counselling.

The consequences of loneliness can result when a person does not have quality relationships. 

• Emotional loneliness: Missing a particular person, and although they have a circle of friends, they do not have a partner with whom to share their feelings. 

• Social loneliness: People may feel lonely because they do not have enough friends or acquaintances, a social network, or even if they live with someone they love. 

• Chronic loneliness: Feel lonely sometimes, but others feel lonely most of the time.

• Situational loneliness: Some people are likely to feel lonely; for example, a person might feel lonely on holiday because they do not have family to spend the holidays. 

Loneliness is both a feeling and something quantified by counting the number of relationships a person has. Having a few social contacts can be described as socially isolated; clearly, a sense of loneliness is likely to occur if a person is socially isolated, but the two are different (Coyle & Dugan, 2012). Loneliness may be associated more with the quality of social relationships than with the number of social contacts a person has.

Risk factors for loneliness.

Dahlberg, Agahi Lennartsson (2018), and Hawkley and Kocherginsky (2018) suggest that some factors may be associated with the risk of feeling lonely, including individual characteristics such as being older, having less education and income, and being female. Additionally, some social factors, such as living alone and having fewer social opportunities, may be associated with the risk of feeling lonely. 

The impact of loneliness.

It is essential to consider that loneliness makes people feel bad; there is a clear connection between the experience of loneliness and poor health. For example, an increased risk of mortality by 26% is as bad for health as smoking 15 cigarettes per day. 

The feeling of being lonely is horrible, so it is not alarming that loneliness also increases the risk of experiencing mental health difficulties. For example, there is considerable evidence that loneliness makes people more prone to depression and anxiety (Beutel et al., 2017; Cacioppo et al., 2006). 

Impact on relationship conflict and breakdown.

Loneliness and being in a problematic relationship are difficult; estimates suggest that in 2017, one in four couples in the UK experienced relationship distress (Relate, 2017). 

Minor disagreements are normal in relationships, but major conflicts, whether persistent or aggressive arguments or cold silences have consequences for those involved. For example, there is much evidence that relationship conflict and breakdown significantly impact physical health. 

Linking separation and divorce to a higher risk of hospital-diagnosed infectious diseases, including cardiovascular morbidities and even increased risk of early death (Sbarra & Coan, 2017). Both relationship conflict and breakdown negatively impact the mental health of both adults and children. Evidence has shown that people in problematic relationships are more likely to suffer from anxiety and depression than those in satisfying relationships (Røsand et al., 2012), and divorce increases suicide risk soon after the event (Stack & Scourfield, 2015). 

Studies have reported that frequent and intense relationship conflicts between parental figures can harm the physical and mental health of children (Harold & Leve, 2012). 

The association between relationship distress and mental health difficulties is not one way; the breakdown of marriage predicts mental health problems. However, mental health problems also predict marriage breakdown. Underlining the importance of mental health influences beyond the level of individuals, specifically those related to broader relational systems.

Relationships abuse and childhood maltreatment.

Many relationships involve conflict, but troubled relationships can be abusive. Extensive research seeks to identify the impacts of these types of relational experiences. For example, researchers have found that having a severe mental health illness is itself associated with a greater risk of experiencing domestic and sexual violence (Khalifeh et al., 2015). 

Having a history of abusive relationships has a greater risk of developing mental health difficulties; the opposite is also true - abusive relationships by research on childhood maltreatment. An example would be childhood experiences of neglect, abuse and trauma, with increasing evidence that childhood maltreatment increases the risk of physical health problems in adulthood, including heart disease, cancer, chronic lung disease, bone fractures, autoimmune disease and liver disease (Nemeroff, 2016). 

Additionally, long-standing and extensive research literature also documents that experience of childhood maltreatment leads to a significantly higher likelihood of experiencing mental health difficulties in adulthood (Lindert et al., 2014; Infurna et al., 2016; Nemeroff, 2016). 

The findings also conclude that nearly half of the participants who had depression reported a history of childhood maltreatment and that those reporting this history were more likely to develop depression in adulthood, had an earlier depression onset, and were twice as likely to develop chronic or treatment-resistant depression (Nelson et al., 2017).

Bereavement 

The universal grief of a loved one that at some point is experienced does not mean it is not devastating, with much evidence showing that bereavement impacts physical health (Stroebe et al., 2007) and has also been associated with an increased risk of death, particularly for those who are widowed (Shor et al., 2012). Estimates of whose spouse has died have a 41 per cent increase in the risk of mortality in the first six months after death (Moon et al., 2011).

The experience of grief is dependent on many factors, including the quality of the relationship and the manner of death. Research suggests that there are two types of death associated with long-lasting difficulties in adjustment: the death of a parent as a child and the death of a child as a parent. 

Experiencing the death of a parent is associated with a higher risk of hospitalisation for depression as an adult, mainly if the death occurred in early childhood or resulted from an accident, violence or suicide (Berg et al., 2016). Similarly, many years after child loss, bereaved parents experience poorer psychological well-being and declines in self-perceived physical general health and physical functioning (Infurna & Luthar, 2017). 

The death of a child is associated with marital distress and divorce; it negatively impacts the parents' relationship (Albuquerque et al., 2016).

Attachment theory.

Attachment theory describes how human infants become attached to their caregivers and the long-term impacts of differences in the qualities of these attachments on later relationships. This theory states that the repeated experiences that infants and toddlers have with their caregivers create learning and expectations about self and others in a relationship. 

Research on attachment has suggested that different types of learning lead to distinctly different types of 'secure' and 'insecure' attachment, which are associated with particular ways of being in relationships. Even if no substantial evidence exists for a direct link between an infant's attachment to their caregiver and the quality of essential relationships in adulthood, this does not mean there is no influence. 

The psychodynamic key theory is that the history of relationship experiences in childhood might partly explain current relationship difficulties. Such as the long-term impacts, for instance, experiencing the death of a parent in childhood, the effect of family conflict and parent separation on children, and the impact of childhood maltreatment. 

Attachment research suggests that insecure attachments are more likely, which means that attachment status may help to explain why these terrible experiences lead to all the negative impacts. Research has also found evidence of both current and prospective links between attachment insecurity and the development of various types of mental health difficulties, including depression, anxiety and eating disorders (StovallMcClough & Dozier, 2016). 

For counselling, attachment theory provides a valuable framework for making sense of and working with relationship difficulties. 

Theories of grief.

The goal of mourning was to allow the person to let go of their attachment to the person who had died, with grieving being a painful process necessary for a bereaved person to move on with their life. 

1. Accepting the reality of the loss is the baseline to healing. 

2. The process of working through grief and pain is where the healing process starts. 

3. Adapting and adjusting to change and learning to live without the deceased.

4. To establish a connection with the deceased whilst moving forward in life. 

Loneliness.

Loneliness includes not having enough or a good enough relationship and how this can affect our mental health. The Campaign to End Loneliness argues that loneliness is bad for people and negatively impacts not only their physical health but also their mental health. 

In December 2018, the Scottish government launched a national strategy to tackle social isolation and loneliness. The NHS encourages social prescribing to replace therapy or medication for lonely or socially isolated people. Social prescribing aims to help people connect with organisations within the community. 

The underlying type of behaviour is that people who perceive themselves as not fitting in or being socially rejected may become more wary and unfriendly in social situations. They may become less inclined to make a social effort and lead others to interact with them less or more unkindly, increasing the likelihood that they will see themselves as not fitting in. 

According to psychologists Tzouvara, Papadopoulos, and Randhawa, more research is required to treat loneliness in therapy effectively. However, what is likely to help a person think about how they interact with others and whether there are ways that they think or behave that make it harder to make connections with others?

The impact of relationship conflict.

Breakdowns in relationships for people living together often mean working out who gets the children, who gets the pets, and who takes which possessions, which impacts both physical and mental well-being. 

The costs of relationship breakdown to anyone who has ever experienced a relationship breakdown will have first-hand experience of the emotional fallout. Often, they are severe and may include a reduced ability to trust or lower self-esteem. One impact of relationship breakdown that frequently emerges in the longer term is friendship loss. 

When couples are in a relationship, they may socialise with other couples, and when the relationship ends, the newly separated people are placed separate from invites to gatherings. Additionally, couples often introduce their friends to their partners, and if the relationship ends, the person who was not the original friend may also lose out on that relationship. After the breakdown of a relationship, one of the couples was to meet someone from another couple together; they often find that those friends choose to maintain contact with only one person in the relationship. 

Overall, people experiencing relationship loss can suddenly have fewer friends at a time when they may need them. A paper titled 'Who gets custody of the friends?' concluded that people in this position could struggle to reconcile their experience of abandonment or distance from former friends with the understanding that friends should provide strong emotional support when they are going through something. 

A second impact of breakdown in couple relationships, whether formally married or civil-partnered, is financial pressure; people who live together often share bills and possessions from household objects, including custody of the children and pets. With the relationship breaking down, the household frequently does, too, so the question of how to split the possessions and how both people will manage financially in this post-relationship life. 

With the differences in career structures and salaries of men and women in heterosexual couples, there is evidence that, on the whole, women come out of relationship breakdown worse off financially than men. A study by Fisher and Low, 2015, found that married women have a 51% reduction in household income and for women who are cohabiting and not married, the income loss is 31%. 

For men, the researchers found no differences between married and cohabiting men, and following the relationship breakdown, their income increased by around 20%. Researchers have tried to understand why married and cohabiting women's outcomes differed. One idea discussed is that previously married women tend not to return to live with family, while women who cohabit are more likely to do so. An essential factor is that living with family costs can be shared. 

Helping couples and individuals who experience a relationship breakdown with counselling for those struggling or struggling to move forward in the aftermath. 

Many people go through a relationship breakdown, never seeking professional support. However, distress related to a relationship breakdown is a common reason to seek help; in the US, 46% of couples seeking marital therapy listed concerns associated with a potential relationship breakdown or seeing if the relations could be saved as their primary reason for seeking marital therapy (Doss et al., 2004). 

Akhtar, (SAC Dip), Lead Counselling Psychologist. 

www.akhtarcounselling.co.uk