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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