Families in Psychiatry

Changing the dance


I supervise the family clinic in the outpatient psychiatry resident-run clinic. The Suttons are a typical couple, encountered by the new resident, whom I will call Dr. Suraj. Initially, Dr. Suraj is enthusiastic in his meeting with the Suttons, but soon enters into a conundrum and brings the case to supervision. The couple has an intricate inexplicable dance, leaving the resident baffled. Let’s review the case. (I have changed several key details to protect the couple’s confidentiality.)

Ms. Sutton presents with complaints of “depression,” and slowly, it becomes clear that her complaints center on her spouse’s deficiencies. “He doesn’t understand me; he doesn’t know what it is like being depressed.”

Other complaints follow; some are practical, such as: “He doesn’t help around the house.” Ms. Sutton’s complaints mostly reflect her perception that either her spouse does not care for her adequately, he has lost interest in her, or he is fundamentally unable to respond adequately to her needs. “He says bad things to me, like ‘Just get over it,’ or ‘Don’t make such a fuss about things.’ ”

After three further sessions of listening to her complaints, and a general lack of response to prior and current medications, Dr. Suraj decides that Mr. Sutton needs to come in. Dr. Suraj follows what he has been taught so far: Get a history from the partner to validate symptoms, functioning, and quality of life. Mostly, the session goes as predicted, ending with Dr. Suraj’s attempt to educate Mr. Sutton about the signs and symptoms of depression. It doesn’t come out right, because the impression that Mr. Sutton gets is that Dr. Suraj is siding with his wife. This seems to make things worse, as Mr. Sutton then complains to his wife that “The doctor doesn’t know what he’s talking about,” “is too young to understand,” or a myriad of other put-downs. Ms. Sutton, of course, tells Dr. Suraj about all of this, following it up with “Don’t worry Doc; you are doing a great job.” Other comments are more in the way of commentary: “I told my husband what you said last week, and he disagrees with you.”

Dr. Suraj realizes that “something is amiss;” the case is stuck, and worse, he is stuck in the middle. The general impression, says Dr. Suraj, “is of a woman who feels victimized, neglected, or overlooked, but somehow, she has the power. She presents as the victim but also is the victimizer. He seems to be the victimizer and tormenter, but all in all, just as much the victim of her torments! I do not know how to think about this couple: They seem stuck, unhappily but inexorably stuck together in perpetuity.” Can anything be done to change this relationship?

Dr. Suraj’s uncensored thoughts: Perhaps they should break up or at least stop complaining. What is it that makes people keep complaining about their relationships? Either they accept it or they leave.

Initial areas of focus

Interpersonal violence. The archetypal extreme is that of an abusive relationship, where the victim is subjected to domestic violence. As I wrote in Advances in Psychiatric Treatment, many relationships where violence is present are bidirectional (2007;13[5]:376-83). Couples may not voice this concern for fear of the spouse being turned over to the police. I usually include a question such as: “How many times do your arguments include pushing or shoving or things like that?”

Asking about income, specifically, who controls the finances and how money is spent, clarifies whether one person feels that he or she has no option but to stay in the relationship.

If intimate partner violence (IPV) exists, there are typical protocols for helping the victim leave. When IPV is not a consideration, the resident wonders about the Suttons, when the victim and abuser change or share roles. Why do they keep up this struggle if they are unhappy?

Life expectations. Many couples do not discuss their expectations or what they imagine will happen when they get married. There may be unspoken fantasies such as “I always assumed that you would retire at 65, and we would go traveling together.” People may change their minds, or life circumstances change so that expectations and fantasies about their life together can no longer be sustained. Are there goals that have changed? Are there dependent relatives that prevent marital goals from being achieved? Is there a lack of agreement about what are important life goals?

Change! One spouse may try to make the other person change, according to his or her preferences. In the psychiatrist’s office, this can take the form of pathologizing: He just wasn’t brought up to talk about feelings, meaning he needs to talk about feelings. We hear questions such as: “Can you take him on in therapy?”; “He doesn’t listen ... can you check him for hearing loss?”; “She doesn’t remember what I said: Can you check her for dementia?” These complaints may come up at the beginning of a relationship or later in life, for example, after retirement when the couple is home together for extended periods of time. Is the expectation that each person should be able to fulfill the partner’s every wish and desire? Be all things? That is a tough order.

The Suttons report that change is the main thing they want from each other. After a full family assessment, it is clear that roles are evenly and acceptably shared; they have no differences in family rules; they both enjoy the same hobbies, care for each other, and work together to solve family crises. However, they cannot accept each other the way they are. When the children were young, she said: “I was too busy to get depressed.” Mr. Sutton states that she now wants him to be attentive to her but he is too tired after a lifetime of work, and anyway, she is so whiny he does not want to be around her. So they bicker back and forth, neither giving an inch.


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