Dr. Ellyn Bader

Helene’s Case: Short-Lived Interventions

I am working with a couple who seem to do well and then crash and I am realizing that I am on that ride with them. I initially saw the wife through her EAP for disability-leave because of IBS symptoms that were exacerbated by work stress.  She also experienced sexual abuse between the ages of 5 to 7 from a family friend and her father. She grew up in the Philippines and is the oldest of 4 siblings. She has been in the States since age 12. Initially she was reluctant to talk about her abuse and her description minimized what happened to her. She had never addressed the abuse with previous therapists and initially she talked about her concern for her younger sister who had been sexually abused by an uncle. Dealing with him and her family’s passiveness about ‘that stuff happens and just move on’ was one of her presenting problems. Also addressed were her current issues:  setting boundaries with her family who had constant expectations of her including lending money; relating to peers on the job; feeling that co-workers were talking about her and worrying about her absenteeism due to the IBS. She initially had a hard time saying no and overextended herself with family. Presently, she has been successful and consistent about setting limits. One of her narratives is that she is not worthy of her husband’s love, then she berates him verbally if she feels he is being sarcastic or disrespectful. She is right about his sarcasm which she sees his father doing and understands that he too reacts, as she does, when triggered. Both of their parents are still married. Her parents live near by, his parents are in South Carolina. She describes her mother as stuck in ‘the old ways’ and has a gambling problem. Her father did have a drinking problem back when he ‘touched my bottom’ and has since stopped drinking and apologized to her. His parents have what sounds like a happy relationship and his mother is a source of good advice for both of them. Problems have arisen because both speak to extended family during an argument–seems to happen impulsively and then they make up and have to deal with the families reactions to the information they have divulged during the upset.

 

The wife’s progress with individual treatment addressed present day triggers with learning coping skills of breathing and resource tapping to calm down. She is also aware of good diet and exercise to modulate her stress and decrease her IBS symptoms. She also complained of constant rumination especially after an argument with her husband and also had ongoing symptoms of depression and anxiety, so I referred her to a psychiatrist to re-evaluate the meds her PCP had prescribed. She had been taking Zoloft, Ambien and Xanax for several years which obviously were not working. She had also been self-medicating with marijuana which she presently is not using. After several med changes, she is currently taking Pristique, Resperidol, Mertazipine and just recently was able to wean off of the Xanax. Because of the history of abuse, the psychiatrist recommended her trying EMDR. I am not certified, so she was referred to an EMDR therapist. Since insurance does not cover this treatment, she has had only 3 sessions so far due to finances.

 

Since it became obvious that a present day trigger is this couple’s interaction, I suggested that her husband attend sessions. They have been married going on 6 years with an engagement period of 9 months. They met on-line and had immediate chemistry and when things are good still do. He is black and because of the racial difference, initially the wife had to convince her family to accept him. She feels that some family members still judge, but there is no overt disapproval. The couple therapy initially went well. They both could intellectually understand their brains’ tendency to react and the senselessness of continuing an argument when they were both in a limbic state. In session, using the I-I works well, but taking that home and applying it when an argument occurs has worked, but only intermittently. They both are invested in the relationship and sincerely feel that they love each other, although this is from a symbiotic perspective. Neither are differentiated, although I would describe the husband as practicing. From an attachment perspective, the wife is along the anxious-ambivalent and at times disorganized style. The husband can display secure behaviors, but under stress is avoidant. Given the abuse history, I was concerned that they may be having sexual difficulties, but for the most part they both enjoy and depend on their sexual relationship.  The wife states that her husband honors her requests if something makes her uncomfortable. To add to this, the wife disclosed to me that she was bi-sexual and that they had an open marriage. The history of this is that she has not acted on the open option with either sex and that her husband has had only one sexual relationship. Her agreement to go along with this was that he not ejaculate inside the other woman (?). This arrangement was short lived since all the problems developed. The open situation is not currently going on and both agree that would just add to their relationship stress.

 

The husband was invested in seeing his wife get well, but as her reactivity (and his too) have continued he is saying that he does not know how much longer he can take this. Their arguments are over simple things and during a replay in session they can usually come to a healthy resolution and they seem to be able to generalize this with some situations, but then something sets one of them off and it starts over again. I can see that it is the triggering that they do to each other that sets them off. I am also noticing that when the wife started her new meds she had a positive response and thought she could see improvement. Her husband noticed the change too, but she was soon back to the pre-med reactivity. I noticed too, that after the first few EMDR sessions she commented that it was helping, but soon too that seemed to lose it’s effectiveness (only 3 sessions, so that is hard to tell at this point). I have conferred with the EMDR therapist and she agrees that with the extent of abuse a longer and more frequent treatment is going to be necessary. Also after a successful couple session there is good progress for a while and then the follow thru drops off. I am looking at this as a placebo effect–if anything seems to work and the wife’s belief that it will is there she can follow through, but if she ‘fails’ she goes back to feeling that she will never get well.

 

The latest is that the husband had threatened divorce, although that was short lived. He has decided to discontinue couple therapy for now because of the lack of progress. I have seen him individually also and he describes feeling guilt-ridden and hopeless. When their relationship is going well he rides that wave until it crashes. He is the oldest of four and a caretaker and enabler. He likes to be in control, but when he can’t manage he becomes despondent, then when things get better he can recover quickly, while his wife takes longer. He tends to ‘implode’ and then explodes when he has had enough. He is a manager at his work and has a difficult time having his work interrupted, but his wife when upset can send up to 10 texts in a row expecting an immediate response from him. I have lately been included in this texting marathon and have been able to short circuit the reactivity, but again the success is short lived.

 

Individual sessions with the wife now are focusing on her ability to stay calm and practice what it takes to not react which she can do up to a point. I hope to have her husband return to therapy. My question is am I missing something? I have been seeing them for almost a year now. I believe that they have the ability to have a healthy and nurturing relationship and they have proven that in short spurts. I tend to be optimistic and work from a try harder stance and I genuinely like both of them and see so much good. So far when a relapse occurs they both have been willing to continue trying. Because there are so many factors progress is slow. The wife’s reactivity due to early abuse seems to be a big issue and one that at times holds her emotional hostage, but when they work well together they do assist in each other’s growth. Progress is slow. I feel that good work is occurring, but the frequent relapses make me wonder about my effectiveness. Should I be doing something different? And I have to ask myself, am I doing most of the work?

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10 Responses

  1. Hi Ellyn,

    Sorry this has taken me so long to reply. I have out of town family visiting, so extra time for myself is at a minimum. The wife is 32 and the husband is 31. I have found the I-I continuums be very helpful. Beside having them see where they are on the continuum, I printed the different levels on separate cards and had each select a level they chose to aspire to maintain during the session. The larger printed cards are a reminder where they want to be with their partner and I have them take the reminders home wth them.They do so well for the most part during a session, but the level of regression this couple can sink to when stressed has me challenged. I have taken this week off to travel with my family, so will not be meeting with them, yet intermittently still get texts. At this point, even though I still receive texts from the husband as well, he has not scheduled an appointment. The wife is continuing therapy on an individual basis. They are both now saying that they want to separate, but currently have no place to move and the husband’s family is arriving the first week of December for a visit and staying with them! His mother has been a positive resource for both of them, but the husband likes to present himself as calm and encouraging (for the most part, he achieves that in session), so it will be interesting to see how he does with company in the house. There has been a new crisis–the wife lost her job last week because of all her absences. He is resentful about this because he thinks she did this to herself. He does not admit to how his constant criticism contributes to her stress. Fortunately, she has shown some real progress about not reacting to his sarcasm. She has even outlined a plan to go back to school while she collects unemployment. What I am now seeing is that as she improves, he regresses. Of course, he is feeling the weight of being the sole provider and resents having to add her to his insurance. Their initial plan was that both of them work, save for a house (they currently rent from the wife’s aunt) and a financial base so she can open a child day care in their home. They have never had plans to have children of their own. I saw his disappointment and impatience all along as he realized the slow progression of his wife’s recovery and the realization of their plan.
    Currently, I am not sure about the salvation of their marriage. I am encouraging them to take individual responsibility for themselves. I have recommended the book, Taking Space by Robert Buchicchino which describes several plans to separate emotionally, even if not physically and focus on individual self-growth. I have seen them bounce back to trying again so many times that there is no telling how this will go. Thank you, Ellyn and everyone who has provided feedback. Along with my delay, I had problems posting, so hope this goes.

  2. Ellyn Bader says:

    Helene-I am not sure, but how old are they?
    I would think of this couple as being very early in the process of differentiation, made more difficult by her abuse history and by the over-involvement with extended family.
    They have many strengths and many challenges. Keep stroking their strengths and outline any bits of progress as they deal more effectively with their triggers. Using the I-I continuums might be a way for them to see and assess their own goals and their own progress.

  3. Meg Luce says:

    Hi Helene,

    My goodness, this is a tough case! I really like all of Jane’s suggestions and can think of a couple that I work with that may be helped by these interventions as well.

    I keep thinking about the husband reacting to the wife’s barrage of texts while he is at work. This may represent a microcosm of many of their interactions. It sounds like he is operating from the symbiotic position that he will either be angry (and explode) or not angry, depending on his wife’s actions—in this case, whether she blasts him with texts. In this way he places responsibility for himself in her hands. A more differentiated position would be that he could decide what he is going to do in response to the texts. For example, he may want to tell her ahead of time that he will choose to ignore the texts at work and take charge of his own emotions. In this way he can take more responsibility for himself and feel less victimized by her actions as she works to manage her reactivity.

    Good luck with this challenging case.

    • Hi Meg,
      Yes, the barrage of texting is a microcosm of many of their interactions. I like your description and it reminds me of how so many separate, little incidents seem to rotate in their own orbits around a central theme that is really difficult to disrupt. The husband has agreed that he will not respond to argumentative texts while at work and he can ignore them, but the latest is that he complained to several members of his family about the texts and the subject. This argument was around his wife’s IBS symptoms which she had “brought on herself by overeating.” When his wife hears from family members that this is being openly discussed she is understandably embarrassed and angry at him for sharing her business. She, in the past, has complained about him to his relatives and he was livid. She has agreed to settle their differences between the two of them, so it is surprising that he, who usually likes to keep things private, is letting his family in on their (her) business. The difference is that she was complaining about him and he is now complaining about her without implicating himself. Your comment about a “more differentiated position would be that he decide what he is going to do” (not respond to texts) which is what he has let her know he was going to do, but instead of managing his own emotions in a positive way he discusses their problems with other relatives which in turn causes more reactivity in his wife. The last session (3 weeks ago) I had with him was an individual session which he requested and was the most positive session–mostly good reports about how well they were doing and he was very emotional about how painful it was for him to see his wife struggling. He strives to be self-controlled, so I think a lapse in discipline like overeating–which caused the latest IBS symptoms is hard for him to forgive. I plan to call him for an individual session (still has not agreed to return to couple) to exam with him this current situation and re-evaluate goals to deal with how he is handling –Meg, I think you are right–feeling victimized by his wife’s latest problems and decide how he can handle his reactions in a more pro-relationship way. Thanks so much for your suggestions. This is really helpful.

  4. jmryan says:

    Hi Helene. I read your case a couple of times and I think it’s really complex. I think you have done a lot of amazing work with this couple, and that their overall pattern with therapists is that they do well in sessions but lose their focus when they are on their own. (EMDR therapist, medication, etc) I don’t know if this is something you have already tried, but one thing that I thought of was for them to have a very specific plan to put into place as soon as they feel triggered. Starting with a signal to each other that they are feeling agitated and then how to proceed from there. This would require each one identifying physical sensations and internal thoughts that happen when they are going into fight or flight. Then perhaps, helping them devise structured individual plans they can implement to calm down and self reflect during a time out. And a structured way to come back after the time out, focusing on how they felt, not on blaming the other. It seems that if they have a structured plan (almost a script) to put into place, it could give them the direction they need when they are by themselves.
    I was also thinking of something Ellyn did with one of her couples, which was have them record themselves talking about a difficult issue or working through a conflict and then bring the tape into you. I think this might help them think more clearly and intentionally during the conflict, knowing you will listen to it. You can use it to point out all the stuff they did well and express their ability to handle conflict well on their own.

    • Thank you Jane for your response. I like your idea for structure around reacting and I agree that structure does seem to set them on the course they both intellectually want to go. I have written down prompts on cards, ex: ‘Do not take this personally’; ‘I can remain calm and listen even though I don’t agree with what my partner.’ Having them try that at home with a specific plan would be a good continuation of what they have been able to accomplish in session. Recognizing body sensations when they are triggered is a challenge. I have video tapped them in session to show how their body language triggers each other and they were very receptive especially when they could see for themselves what they were doing that was triggering their spouse. Having them tape at home as Ellyn suggested would provide them a clear description of how they escalate, but the challenge is catching the point of take off! They have worked hard on establishing rules for Time-outs and the mantra, “I am going to stop now because if we continue we will only hurt each other” can be initiated by either and worked for a while… They know about identifying when they are in “thumb” mode. Maybe it is the consistency and a reminder that they can take home as you suggested to keep them on tract. Blaming on both sides has been a big deterrent. I think that they both get disappointed when they fall into that old escalating struggle, yet both have a hard time recognizing their individual process and instead shift into blaming the other. The blaming they do takes some disentangling for them to gain a clearer perspective of how they each participated. The wife has an easier time recognizing what she did and how she could change; the husband has a harder time not blaming. This pattern probably developed because the wife previously accepted the blame and because he wanted to be the one who solved the problem. This problem has shifted, so that the wife is standing up for herself and the husband has given up on problem solving (kind of). I will try introducing your idea of a scripted discussion after the time outs. The husband came up with the idea of during a time out, a cooling off task for him would be to write down an outline “bullets” to organize and prioritize what were the real issues. Thank you so much. I have not taken advantage of the discussions as much as I would like to–after a year I am still catching up on all the readings and audios, but this resource is so helpful too. I really appreciate your input and will let you know how it goes.

      • jmryan says:

        Hi Helene. I was just reading an older case that Pete had. And he pointed out to the husband that his “problem-solving” tendency was a way to deal with his own discomfort with his wife’s emotions. It was more a protective strategy for the husband. I wonder if this would apply here? If you ever had the husband come back in, perhaps you could discuss this with him and focus on what makes him uncomfortable about his wife’s emotions or emotions in general.

        • Thank you Jane,

          I think you just hit that right on the mark. He is used to being the problem solver in his family and the one everyone looks up to and I think at the onset he figured he could solve this for his wife. He is at his best when he is the one taking care of someone else, which works well for him to avoid his own issues. They have decided to separate. I received a text from him this am describing “…I look at her and feel tired and broken. It’s not the same anymore. All I do is cause her pain”. He is at a low point and I know is feeling as much pain as his wife. Even though he would prefer to hide his more vulnerable emotions, he has cried openly in individual sessions. In front of his wife he holds back and she has been hurt by his inability to let her be there for him, even when he is ill. I have requested to have them return for a session to formulate how they are going to do a separation. If you still have the date on the call you described, I would like to listen to it. Thank you for the suggestion and I am hoping to have the opportunity to give it a try.
          I really appreciate this feed-back

          • jmryan says:

            Hi Helene. I am glad you think this might help and I hope you do get a chance to talk to him about this. It actually was not a phone call, but I was re-reading the lessons, and it was in Lesson 2; it was in the Sample Interview. It is just brilliant how Pete brings around to the husband that his wife’s emotions make him uncomfortable and its his issue that leads him to “fixing”‘ so he does not have to be uncomfortable as he witnesses her emotions. Lots of luck !

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