Couples and family therapy is among the most rewarding work the psychiatrist performs. It is also among the most challenging given that both interpersonal and intrapsychic factors are in play, and the mindsets and motivations of the participants are not always what they seem to be. Despite trying to assess situations before the initial visit, the psychiatrist can wind up in some hairy situations, as I am about to relate.
Over the years I have received many a call from a husband or wife saying, “We need help now. How soon can you see us?” The last time I made such an appointment without inquiring more about the request, I wound up with couple in my office—Katharine and Thomas, we’ll call them —where the woman was so distraught because she found lipstick on her husband’s shirt and a suspicious receipt in his overcoat that she could barely control herself. She pounded on one of the office tables so frenziedly that the noise literally rattled my diplomas. The louder she became, the more he taunted her for acting like a maniac. The noise reached such a crescendo I thought I would have to call the police. Fortunately, no blows were exchanged; he backed off to catch his breath as she reloaded for the next barrage. They were about to start up again when a therapist in the neighboring suite tapped on the door to make sure no one was bleeding. I told Thomas to go for a walk while I talked with Katharine. He was to return later to meet with me individually.
Katharine, a willowy woman in her mid-forties, was a working mother of fifteen year old fraternal twins. She and Thomas had been married for eighteen years. After the children were born, Katharine was diagnosed with bipolar disorder after a postpartum depression for which she was treated with a medication that sent her into a fiery hypomania. It took months for her to recover, and she emerged from the experience very wary about psychiatric care. Since then she had received only sporadic psychiatric treatment with benzodiazepines and minimal psychotherapy. After several years of ups and downs, she concluded that bipolar disorder was a misdiagnosis; that her real problem was poor choices in men. She self-medicated with alcohol and tranquilizers to control racing thoughts and sleeplessness; however, her substance usage had accelerated in the previous eight months as she grew more suspicious of her husband. According to Katharine, her husband was so controlling and abusive that, to use her words, “He would drive anyone mad.” She minimized the role of her mood issues contributing to the marital discord, claiming that a friend who was also a therapist said she was situationally stressed and depressed because of the marriage. Upon probing she admitted frequent impulsive spending binges and months at a time of racing thoughts. Three years earlier, during a blackout spell after a fight with her husband, she had a one night stand with someone she picked up in a bar. When Thomas found out she begged forgiveness, promising to get help, but dropped out of treatment after only a few sessions when it became clear to her that the psychiatrist and the psychologist “insisted there was something wrong with me.”
As a child and adolescent, Katharine had frequent tantrums. Presently, she lost her temper—worse during her menstrual cycle—when her daughter didn’t do chores or homework as promised. Her son didn’t want much to do with her either. Katharine had played piano proficiently until young adulthood, but never recovered her dexterity after she ripped two tendons on her right hand slashing metal venetian blinds in a blind rage at her parents when they said, “No,” to her request for money to travel abroad.
When I met with Thomas alone, he readily admitted the affair. In truth, he was glad the matter was out in the open. He had had it with his wife’s moods and the fighting over money, which according to him, she spent impulsively without regard for the budget. The couple had agreed to tighten their belts to save for college tuitions but she continued impulse-buying, claiming that because she was working, she was entitled to spend money however she pleased. Whenever he confronted her she became enraged, accusing him of being controlling. According to Thomas, Katharine claimed she was the victim of “spousal mental abuse”—a term she discovered in a woman’s magazine—because he refused to cosign a large cash advance from their home equity credit line which she wanted to use to set up shop flipping houses with a divorced friend, even though Katharine had no experience in real estate.
At the outset of the relationship—they met at a holiday party—Thomas, a quiet man who hadn’t dated much, was attracted to Katharine’s lively emotionality. Their courtship was divine, he recalled, Katharine saying she was walking on air. But that ended abruptly when she pitched a fit on their honeymoon because he refused to indulge her impulse to buy an extravagant bracelet. She pouted for days, ruining the rest of the trip. Over time she became strident and irritable, worse during her menstrual cycle. Katharine went into a severe postpartum depression after the birth of their twins, for which she sought treatment reluctantly, then quit abruptly when the medicine agitated her. She blamed Thomas, saying she would have been just fine had he not made her take the capsules. When Thomas said he hadn’t made her do anything, she erupted afresh, setting a pattern lasting over the years where he “walked on eggshells” to keep from upsetting her. Whenever he suggested she get help with her mood and drinking, or proposed that the couple go for counseling, she refused, excoriating him about the debacle into which the first therapy had deteriorated. He was the problem, she declared. Why should she have to bare her soul to a stranger knowing her husband would make her out to be “crazy?”
Although Katharine denied having a family history of mental illness when she was with me, Thomas said that her family of origin was rife with mood and substance disorders. An uncle had shot himself in the head, although the family made it sound like a hunting mishap.
Feeling unloved and living in fear of his wife’s next outburst, Thomas confided in a sympathetic female coworker at his law firm, and what started as an amour de Coeur gradually evolved into a hot and heavy romance; both he and his paramour were thinking of leaving their spouses for each other. Was he certain he wanted a divorce? Not totally. However he had stopped trying to conceal the affair and arranged to be caught. He had already seen to a divorce lawyer weeks earlier.
So why had they come to see me that day? Katharine, overwhelmed with rage and jealousy, made the appointment, feeling she had proof positive that justified her outbursts. Was she seriously thinking about help with hers and Thomas’s relationship? Not at all. Consciously, she wanted a therapist to validate how wronged she had been and how entitled she was to her rage, the depth from which there was no escape unless I could extract a promise from Thomas to end the affair immediately. From Thomas’s perspective, he came to the initial visit consciously hoping yet again to get his wife under a doctor’s care, so he could leave the marriage gracefully without Katharine decompensating into either a bloody, full-blown mania or a debilitating, deep depression.
Was Thomas sure he wanted to marry the other woman? Not really. He was very depressed about his marriage. A moral man, he felt guilty all the time. He knew Katharine was very psychologically ill, but how much was he supposed to endure from a woman refusing to acknowledge being ill, let alone get help? Thomas’s friends and family said they would support his decision to leave, seeing he had given Katharine many chances to get help and that she lacked the motivation and insight to change. Still, to Thomas, divorce meant failure, and he was in deep conflict about breaking up his and his new love’s family. What he wanted more than anything at the time of the first encounter was quiet and emotional space to think rationally about his future. The idea of slogging through a bitter divorce and custody battle sickened him, although he couldn’t see living the rest of his life in such a tumultuous relationship.
For certain, the couple was in no shape for conjoint sessions; their agendas were at such cross purposes. Katharine’s mood was much too unstable; emotional eruptions would only inflame her more. Meanwhile, Thomas was much too ambivalent about the marriage and the affair to assess what he wanted from both relationships.
What to do? The first issue was safety. I told each of them separately that they needed a cooling off period. For the present, there could be no conjoint therapy because, with emotions were running so high, it would be incendiary. Was Katharine so angry that the couple could cohabitate without risk of violence? No, she said pulling herself together quickly, realizing that she was on the verge of being told she needed hospitalization. Thomas, however, was happy to stay with a family member living nearby as long as he could see his children.
The best thing to emerge from the first day was that Katharine agreed to come to a follow up individual session the following day, where she wept, saying she knew she had driven her husband beyond the brink by her behavior. She used pills and alcohol to manage sleeplessness and racing thoughts. What heartened her was that I didn’t yell at her or stigmatize her with a psychiatric diagnosis at the initial session. She had issues accepting “No,” which infuriated her to a degree beyond which she lost control over her emotions.
Thomas was pleased that his wife had come back for a second visit. He called asking what he should do. I told him not to do anything until he sorted through his feelings, and his wife received good psychiatric care. Did I know a therapist I could recommend for him? Of course, and I referred him to several therapists, agreeing that he needed time and space get a handle on himself.
Katharine agreed to come back for a third visit; she didn’t call it therapy, nor did I. If there were to be a sustainable therapeutic alliance, it was clear we needed to make the experience more palatable than what had gone on before. She would need a sense of control were she to engage in therapy. Rather than establish a fixed appointment schedule, I followed her lead about how often to meet. To begin with, Katharine could not tolerate being psychiatrically labeled. The best she could manage was the face-saving admission that she wanted needed help, “Calming my mind and helping me sleep better.” She hated psychiatrists who diagnosed people without knowing them. The way she saw it, the first psychiatrist was doctrinaire and derisive regarding women’s issues, prescribing Prozac for her postpartum depression after only a few minutes evaluation. Long before then, Katharine knew she had mood swings but she didn’t want her or her family to think of her as “mentally ill” because of the contempt with which the family derided “crazy” Uncle Albert, the man one who drank too much and died in the hunting accident. The family scuttlebutt had it that he was a gambler and womanizer who invested in one get-rich-quick scheme after another, squandering his last penny on internet stocks.
Katharine accepted medication for her “condition” as long as we understood that it was to calm her racing thoughts and help her sleep. Despite urging her to stay off the internet she came to the ensuing session very upset, having read that Seroquel, the medicine I prescribed, was used for schizophrenia and bipolar disorder. I had promised not to label her. Why was I treating her with medications used for crazy people? What followed were several difficult but essential discussions over the next month about psychiatric diagnosis and overlapping symptoms between depression, manic depression and schizophrenia. “You don’t think I’m crazy?” she asked over and again, until it finally got through that her life would go much better if she could accept having a mood disorder, rather than fighting the diagnosis until she destroyed her life. The relationship with her daughter was deteriorating rapidly and her son kept on asking why she was always yelling at his father. The diagnosis “bipolar disorder” felt like a dagger to her heart. Couldn’t we agree to call it something else? Like many misinformed individuals, Katharine thought that acknowledging having bipolar disorder would be the end of her life, as opposed to the beginning of a new and better one. I gave her Kay Jamison’s memoire The Unquiet Mind, explaining that some of the most creative and well-functioning individuals were bipolar patients who had learned to run their emotional lives, as opposed to being run by them.
By the end of the Katharine’s first two months of treatment Thomas moved back in but it was still too early for conjoint visits. In individual sessions, Katharine and I focused on modulating the key emotional states that sent her through the roof: being told, “No,” induced a feeling so painful that it defied rational judgement. In her grandiosity, she aspired to great wealth and power: for her Thomas’s home equity loan denial meant he didn’t have faith in her, even though the truth was that she had become feverishly excited by many a new project only to crash and lose interest when they proved difficult or disappointing.
It wasn’t until many months into Katharine’s treatment with psychotherapy and medication—we had to be careful of her diet and exercise regimen because of Seroquel’s proclivity to stimulate appetite and weight gain—that I felt she had developed enough insight into her own condition and control over her emotions to profit from conjoint therapy. By then she was slipping into depression, reacting to Thomas’s obvious coolness; true he was concerned about her, but she could see that his spark of affection was dying. Katharine felt sure Thomas wanted a divorce, so she wanted me to do the couples therapy, figuring I could plead a better case for reconciliation since I had witnessed the changes she had made in therapy. But I insisted on a neutral party in order to preserve the therapeutic alliance between Katharine and I, which would be especially important if and when conjoint therapy would be upsetting, which it was bound to be. Before conjoint therapy, I prescribed lamotrigine for bipolar depression, hoping to cushion the impact of the inevitable difficult moments.
Not surprisingly, it turned out that Thomas benefitted greatly from his individual therapy, coming to conclude that he and Katharine were a poor match, and that he couldn’t get past the memories of the nasty diatribes; they would be better off emotionally were they to separate permanently. What the conjoint sessions did was help both parties put their children’s needs above their own battered feelings and to minimize the financial damage of divorce by using a mediator to settle their affairs rather than draining the estate through protracted litigation.
Katharine needed individual therapy while the couple’s sessions proceeded to adjust her medication and cushion the depression as her dreams of reconciliation were dashed. Had she really loved Thomas? The painful truth was no. Her mood had been too chimeric as a young adult to maintain a stable, loving relationship. She had fallen in love with the intoxication their courtship evoked in her— the first euphoric high of her life. The good to emerge form therapy, both individual and conjoint, was that she finally came to accept the lifelong need to master her mood disorder.
Katharine and I still meet regularly for therapy and medication. The issues on the table are single parenthood and coping with her moods as she enters perimenopause She takes pride in sharing stories where she masters upsets where her “old” behavior would have proved disastrous. She and Thomas both love their children and co-parent better than they ever did. Katharine has just started dating, where it pains her to realize she trashed her marriage because of her mood issues. Should she have married Thomas? No. The truth was that she wasn’t emotionally mature enough to marry anyone. She never had a real boyfriend before Thomas because she hadn’t learned that compromise was a prerequisite to sustaining a loving attachment. To her, not getting her way, as she felt on her honeymoon when Thomas refused to indulge one of her whims, felt so painful it overwhelmed her capacity to see the good he brought to the relationship.
All along, Katharine knew subconsciously that she would never be ready for marital therapy until she had a handle on her emotions, which played itself out in the timing of conjoint therapy when Katharine and Thomas came to me in crisis. Perhaps, however, a deeper lesson in Katharine’s story is how important timing is in the treatment of bipolar disorder. Had Katherine obtained truly effective psychiatric therapy as a younger woman, the entire trajectory of her life would have been different.
To her credit, Katharine asked courageously that I tell her story. She wants others to know that accepting the diagnosis of bipolar disorder made it possible for her to begin anew, and she hopes others with mood disorders will accept help earlier in life, before irreparably damaging themselves or their relationships. So when it comes to the matter of getting help, Katharine agrees: “Timing is everything.”