Do therapists offer one tissue or help the whole family?
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Individual therapy is often very helpful. At the same time, for an individual who is married and unhappy in part because of marriage problems
, beware. Furthermore, an unhappy individual is fairly likely to have unhappy children. See the paragraphs at the bottom of this article to understand the potential gravity of this reality. Yet how often do therapists check out how the children of their adult patients are faring?
"Physician do no harm" is a first principle for all professionals who work in mental health as well as in the arena of physical health. Katrina (name changed to protect her confidentiality), who is a dear friend of mine, suffered for many years with breathing and heart problems. Katrina's lung doctor and also her heart doctor had worked vailiantly with various medications to alleviate these problems. Then Katrina moved to another state. Her new physician there looked overall at her full body functioning, and from the tests immediately diagnosed a long-standing, slow-growing colon cancer. By including in the diagnostic and treatment process the full person rather than just the area of specialty of the treating physicians, the new doctor indirectly healed the lung and heart problems as a by-product of the cancer treatment. Similarly, evaluation of individuals who seek therapy needs to include assessment of the couple if that individual is married, and also of the children if the primary patient is a parent.
A crime? I admit, that's an overstatement. Individual therapy for a married person though can be an inadequate and therefore unethical model of treatment.
I recently have been treating a couple in which one spouse, let's call her Anna, had been in individual therapy treatment for several years. Anna liked her psychiatrist. He was a "nice person," and talking with him was comforting. He had been truly helpful in clarifying what in her up-bringing had caused her much distress. Unfortuately, however, the psychiatrist knew that his client had been having an emotional affair, and condoned it, in part because Anna's descriptions of her angry husband had created an image of a hopelessly unsympathetic spouse that had seemed to justify Anna's turning elsewhere for comfort.
The psychiatrist meanwhile had never met the spouse, so had no way of coming to an independent assessment of his potential for growth which turned out to be on the extremely high end. In addition, the psychiatrist assumed the accuracy of his client's descriptions of her "defiant" teenagers, and commiserated with his client hearing the way her husband curried favor with the teenagers in a manner that consistently caused her to feel left out.
When Bert, Anna's husband, eventually discovered Anna's affair, which by then had become sexual as well as emotional, he needless to say, was furious. To his credit, while Bert's first impulse was to seek an immediate divorce, after calming down enough to think over the situation he relented, requesting instead that they seek marital counseling. They found my name from the internet.
What couple and family systems therapy can do that individual therapy cannot.
To assess the couple I first worked with them together in an initial intake session. I then saw them individually for one session each to explore the extent to which each partner was willing and able to take responsibility for making changes to their own contributions to the family's difficulties.
By the time we met again the next week to launch the couple treatment, Bert had already determined that he would never again speak angrily to his wife. Instead he would exit any situation he might not be able to handle calmly, bring himself back to the calm zone, and then return to the dialogue. The calming process generally took him just several minutes.
During the same week I also met alone with Anna for a single individual therapy session. I had clarified in my first session with the couple my policy that I only work with couples who agree to end all contact with an affair partner. In her individual session Anna consolidated her decision that she would gradually end contact with her affair partner in order to focus on improving her marriage relationship.
Within two weeks of further couple treatment sessions Anna and Bert had enjoyed, for the first time in years, multiple "date nights" and a renewal of their affection at home. They also had determined that they would work together as a team to mend their full family. Their teenagers, it turned out, had been reacting to their mother's tendency to get over-controlling with them.
Now that she was working within a therapy process that included Bert's perspectives as well as her own, Anna began to see that her over-emotional ways of talking with the children had been a prime cause of their disaffection and also of Bert's protectiveness with them.
The psychiatrist who had worked so long with Anna in an individual treatment format only had no way of gathering a broad enough data base to see his client in any way other than how she presented herself, which was as a lovely, likeable and intelligent woman. Anna's many quick-tempered outbursts at home had never struck her as relevant to her marital or parenting problems, even though from my diagnostic perspective she had been functioning in the manner of someone with a borderline personality disorder. With so little insight, Anna had been unable to share this data with her psychiatrist. Anna's hyper-emotionality showed significantly less in the calm environment of her one-on-one therapist's office, even though her hyper-sensitive amgydala reactivity, along with her husband's anger eruptions, were at the root of her family's disintegration.
The moral of the story
Just as people live in a full body, not just with a heart or lung that is impaired, most individiuals live in the context of a family. The full family, starting with the couple, needs to be included in the assessment and eventually, in many cases, in the treatment. For a therapist to get a broad enough data base to diagnose and treat effectively, the individual therapy client's spouse is best off being part of the treatment and intervention processes.
What if the spouse is unwilling to participate in treatment?
That's tough one. Half a loaf probably is better than none.
At the same time, divorce likelihood goes up with individual treatment unless the treating therapist is highly committed to the insitution of marriage and therefore to doing all possible to help the client figure out how to make the marriage a healthier one before exploring the divorce option.
I generally encourage all new clients to bring their spouse at least to the first session. I say it's my policy. If the spouse still won't join us, I offer to phone the spouse myself, which often proves effective.
At the same time, if a married client says that they do not want their spouse at the first session, I always respect that. Usually that request indicates that either an affair or abuse is part of the problem. Sometimes also however it's some other issue that would have been unhelpful for the spouse to hear.
I do offer individual therapy to all married clients, but as part of an overall family system treatment program. Most couples end up with mainly couples treatment, plus occasional individual therapy sessions on an as-needed basis. To prevent sibling rivalry, I aim for symmetry of individual time. After an individual session with one partner I generally invite the other also to schedule a one-on-one session.
What is he worst treatment format in terms of inadvertently inviting an iatrogenic (treatment-induced) divorce?
Two separate therapists, one for his indivivdual treatment and one for hers, is with highest frequency a recipe for ending the marriage.
Eventually also the children's needs must be assessed as well.
The motivation for me to write this article actually did not come from Anna and Bert. The difficulties with indivivdual treatment for married people is a topic that I discuss at length, with relevant research citations, in my book for therapists From Conflict to Resolution and also in my training video for therapists, The Angry Couple. However the immediate trigger for this post came from the following comment in response to one of my earlier posts on growing up with a borderline parent. Thank you "anonymous" for sharing your experience with us, the psychologytoday.com community.
Dealing with a sick Mom, sick brother, no father.
Submitted by Anonymous on October 28, 2013 - 9:51am.
Until just recently I didn't even realize that my Mom was sick too. I thought it was just how she was. Now after a lot of study and research I believe she had a definite personality disorder. Borderline, manipulative, not sure which of many to call it. My brother was sick too, he was older than me.
My question is, what is happening in this field in regard to the children growing up in this type of environment? Surely you are aware of the devastating effects this can have on them? I'm 59 years old and am just now finding out what was really going on in my childhood home, all these years I have carried the guilt of not being able to help my Mom be happy. With a brother who was sick too, I got it twofold, and there was no one else there. Mom wanted me to take care of her, and she, of course, couldn't handle my schizophrenic brother, so I was in the middle of this and had no clue it was damaging me mentally. My life has been totally dysfunctional and it has taken me this long to even learn that what I lived through was NOT normal. I really would like to understand why the "normal" one of the family was the one that fell through the cracks and if there is something being done for those children now, that are in that same situation. I was married once, at a very young age, it was an escape for me, a way to get away from the home life I lived. After having two children my husband and I split up, and I left the kids with him, believing so deep down in my heart that the reason my brother was messed up was because he had no father. The mental illness was the root of it all, but I didn't know, no one thought to tell me as a child, and although it wouldn't have made it any easier to live with, at least I should have known what it was and maybe would have dealt with my own life in a much different way. Mental illness does not only affect the person who has it, it affects everyone around them.
Final note from Dr. Heitler: The final sentence of this comment says it all and therefore merits repeating:
Mental illness does not only affect the person who has it, it affects everyone around them.
Denver clinical psychologist and marriage therapist Susan Heitler, Ph.D. is author of multiple books plus an interactive website that teaches couples the skills for marriage success, poweroftwomarriage.com.