Sunday, March 04, 2012

T for Two and Two for T.

Today's New York Times has an article about couple's therapy and how difficult this is to do.  The piece is by Elizabeth Weil and is titled, "Does Couples Therapy Work?

I don't do couples work.  I didn't plan it that way, but very early in my career, I realized I'd had minimal training in couples therapy and people with marital problems deserved to be treated by someone who had experience in this area.  

I do sometimes see my patients with their spouses,  or even significant others, and it's always an interesting experience.  I also hear from my patients that they will see their partner's therapist for couples therapy, and I'm never sure how that really works--- to me it seems that the allegiance, or agency, of the therapist needs to be clear.  You're either working for the couple, or you're working for an individual.  I don't know how you do both.

Since I only do individual work, it's very clear to me: I'm aiming for what's in the best interest of my patient.  While I may like or respect or wish the best for their parent/child/spouse/or roommate, my goal is to help my patient.  Sometimes it's a single goal: It's never in the best interest of my patient to do something that will cause physical harm to anyone-- if for no other reason than I think my patients are happier when they live in a setting where they get treated by me, and not by ClinkShrink (--meaning, not in jail or prison). 

Sometimes I ask people to bring in a family member.  Usually this is because either I need more information about the history, the current situation,  or about what symptoms the patient may be exhibiting in their natural environment.  More often, I ask people to bring in a family member because I need to enlist their help in either caring for a patient or monitoring them.  Perhaps someone wants to go off a medication and past attempts have been unsuccessful-- it may be helpful to educate a family member as to what the symptoms of a recurrence are and an extra set of eyes may help catch problems earlier than I would be able to alone.  Perhaps a patient needs more help in negotiating the day-to-day issues in life, like getting to a doctor to evaluate that mass, or to evaluate a memory problem.  

More often, people ask me if they can bring their spouse, and it's not my idea.  I often ask what the agenda is to be, why they want their person to come.  Here are some reasons why people bring others to therapy sessions:
--They want me to fix the other person. (I can't do this).
--They want to confront the other person about a problem in a place where they feel safe (Can I go home now?...This is never fun).
--They just want me to meet the person they talk about a lot.  (I often like meeting them and having a face and live person to put to the stories).
--They want me to explain what's wrong with them to someone who cares but doesn't seem to understand (I'm happy to try).  

In a clinic setting where I see people for medication management, it's not unusual for people to bring family members into every session.  The patient may not be someone who talks about their emotions or feelings, or even has any interest or ability to relay to me stories from their lives.  Perhaps they have a brain disorder (like mental retardation or a history of a disabling stroke) and the medications are targeting disruptive behaviors or psychosis, and the person who comes is often the one to identify whether things are going well or not, in conjunction with the patient.

What are your thoughts on bringing significant others to sessions with a psychiatrist?


Alexis said...

There's one other scenario, which is related to some of the things you touched on: When another person (spouse, family member) is a frequent subject or issue, it can be useful for the therapist to witness their interactions firsthand. I don't mean "maybe they're an unreliable narrator" (it may be true, in fact we probably are all unreliable to some extent) but actually witnessing the interaction can give insight into the patient's behavior, and provides a comparison for the patient's perception of those interactions.

It's not without its own limitations--I remember bringing my mother to therapy sessions when I was younger, and finding it forced and unreal, but that didn't render it useless. (And, my feelings about the situation, that it was a kind of forced performance and that I was unable to behave naturally, would probably have been valuable to my therapist had I been able to articulate them and why.)

Anonymous said...

As you stated, I think it's highly dependant on the client's agenda in bringing the family member in. I also think the relationship between the client and the family member matters as well.

There was a time when I had to bring my mother in on every visit. In most cases it was because I simply could not talk, she had to relay my symptoms and struggles. In one instance I felt pressured to take medications I was against, and needed her there to, in a way, force pleasantries from the psychiatrist and at least provide the appearance of listening to my point of view (yeah, not seeing him anymore). I hated it, I absolutely one hundred percent hated it. I couldn't trust what would come out of my mother's mouth. As much as I know she was trying to do good by me and get me the help I needed, not knowing what she would say, or having her divulge information I wasn't prepared to share yet, made the entire thing very scary, and it affected our relationship while it was happening. I would get upset after the visits and over time found myself getting angrier and angrier before our visits. Now if I so much as see her talk to any of my healthcare providers (had to go to the bathroom once, caught her and my therapist chatting in the waiting room) I froth at the mouth and spew numerous vulgarities in both parties' direction.

She no longer comes into those visits with me. I have people I can work with now, and can speak just enough that they're able to treat me, though not always enough that they can get a clear picture of what's going on when I'm at my worst. There are times where I wish I could bring her in to say things that I very much want to say but can't work up the courage to open up about, but our previous attempts at having her speak for me took a great toll on our relationship and I wouldn't risk having it degrade any further.

It can be a really slippery slope, having family come in. If infrequent, and if the relationship is strong enough, having them come in may be helpful. The more frequent it is, the greater the likelihood it could negatively affect the relationship, no matter how strong that relationship was at the start.

Liz said...

i've never been to "couples therapy" but i have had psychiatrists and counselors that sound a lot like you-- i have had experiences with family/friends coming to a session or two. often, the purpose for these meetings was an exchange of information, with the helper educating my family/friend about my condition or needs, or my family/friend educating the helper about how they felt i was doing. overall, these meetings have been awkward, but beneficial.

one time, though, i had a bad experience with this-- my friend wanted to come to counseling to speak with my counselor. she wanted me in residential treatment, the counselor didn't. i think she didn't feel respected or listened to in that situation.

Sarebear said...

I had a so called friend, the one who got me hooked up with my therapist and my first psychiatrist, well she works with NAMI alot, is very into mental health issues, her daughter's bipolar. I don't know but I'm guessing her daughter is manipulative, because once, driving me to support group, she starting railing on some mentally ill guy who wanted her to do something (she supposedly likes to assist the ill with things they need help with, especially advocacy stuff), she went off on how manipulative he was turning out to be. I thought it was a bit odd but didn't think a whole ton about it til like a year later.

I was having alot of problems with the psychiatrist and, in a moment of frustration, called her and vented about him (she thinks he walks on water, oops), and she said she'd call him and help me out. Whatever that meant, but I had the distinct impression she'd be doing something NICE for me.

She called him and railed at HIM about how manipulative and awful I am (what the hell? I am not where the hell does she get this stuff and I asked my therapist what he thought about what she said and he said she's wrong.) and stuff. I also was pissed in the end that the psychiatrist even talked to her about me, that's unethical.

So, next time I go to the psychiatrist, I find this stuff out, and I'm just shocked, feeling her knife go right in my back, feeling his too since he talked to her for HALF AN HOUR both of them railing on me.

Eventually after a few weeks I thought back to her just going off on that other guy when we were in the car and I thought, "Oh, hell, she "helps" a variety of the ill through NAMI, I'd hate to be one of the people she "helps" if she just slaps labels on you for no good reason etc."

What's even WORSE, is the psychiatrist typed up a summary of the call, full of them agreeing that I'm manipulative and crap (have I mentioned before that he didn't listen to me very well and would jump to conclusions alot?) and I was in the process of my SS claim . . . this paper was front and center in the file at the hearing with the administrative law judge . . . do ya think it mighta influenced them, just a bit?

She'd actually be upset that what she did may have messed with my claim, she was trying to help me with the claim so's I could pay for treatment myself, but I barely talk to her if I ever bump into her anymore.

This incident made my agoraphobia much worse because she involved a couple women from my congregation in her negative, inaccurate judgements of me.

People WILL think the worst of you for NO REASON, just because they CAN. And they'll screw you over just because they CAN.

I have trust issues with psychiatrists, too of course. I still have alot of anger and hurt to process on this.

frenetic said...

Never a good idea to bring the spouse in. Even then, the only time the spouse came in was so the psych could get a history from them as well, concerning my symptoms... which the spouse went on about how annoying I was, and then glossed over/was ambivalent about the diagnosis the psych did give me...

I have done couples therapy... it never went well, particularly when the spouse did not believe in the psychotherapy process. Needless to say, we are no longer together.

Couples therapy only works if both parties are committed to changing themselves, since we can't change the other person. It doesn't work if one is not interested and has checked out of the relationship a long time ago. This goes for spouses/partners/siblings/parents etc.
And it also goes without saying that both partners have to have a good rapport with the therapist - not an easy feat!

Anonymous said...

Brought the spouse in once. Psych said it might help spouse be more understanding. It was awful. Psych said now I know what kind of brick wall you are up against. This made me feel worse, as though psych had not believed me and needed to see it with own eyes.

DBT-Fan said...

When I first got the bpd dx my then live-in boyfriend came to every session with my doc. It helped. I was in a pretty deep hole and wasnt to the point of wanting to get better for myself but I loved my boyfriend as was willing to try for him. Those sessions were invaluable. We learned about how to approach my illness - what I needed to do go start gaining control and the doc explained the boundaries important for my bf to hold. They were less therapy and more war room - planning our attack against the bpd.

It worked for us. As I got better I started attending on my own. Its 14 years later and I happily married that bf 8 years ago. I took him to introduce him to my current therapist and psych doc. He has an open invitation to join me in therapy if he thinks it would be helpful but he mostly feels I manage well on my own. When he has been in a session my therapist starts out with a reminder that she is my therapist and her primary goal is my treatment.

We did do some couples therapy with a different neutral doc who favors cbt a few years ago and I think it was useful to learn a skills all couples should have related to fighting fair and listening. Learning to respect a time out was a difficult skill for me but I'm glad I persevered as it has been useful in preventing my own internal emotional escalation.

Unknown said...

I found this article relieving because as a relatively new therapist family conflict often hits me in the gut. I fight a lot of my own countertransference in trying to treat the family unit when they are fighting and trying to get me to take sides. I guess I should have known I wasn't the only one, but it was nice to know its not just me.

Jane said...

I thought these were some good comments. The Anon poster who brought his/her mom to the sessions faced issues that I had in going with my father as a child. I think there needs to be a lot of trust and respect for privacy. When bringing a family member, it may be important to make it clear about what should not be divulged to the shrink (or should be divulged at a later date). Also, there is the risk that the family member will say something totally false or taken out of context. My Dad was with me every single time I went in for med management as a minor, and he would say things about me that were either wildly inaccurate or taken completely out of context. And most child/adolescent psychiatrists back then didn't interview children except maybe to ask a few questions. The interview was always with the parent. Questions about how the kid feels on the meds were almost always directed to the parent. And it wasn't just me. That was pretty much every kid or teenager where I'm from who was on meds at that time. It was very easy to have information taken out of context, and now I won't allow any family members to meet my psychiatrist or go to doctor visits with me. I think there is just too much risk of false revelations (or accurate revelations that I would not consider necessary for a psychiatrist to know or that I don't want revealed yet).

And Sarebear, I really related to this story you just shared, because sometimes I meet "advocates" who have issues. They get on their high horses and talk down to the people that they are "helping." I think some of them are very down to earth and knowledgeable. I found the most respectful and helpful ones to also be the ones that had knowledge above and beyond what I would expect them to have. The ones that acted like your ex friend tended be very self-important people.

Sideways Shrink said...

I have had some success doing couples therapy and it really does have to do with allying equally with each partner and finding two partners who are interesting in working on themselves and able to engage in the psychotherapeutic process. In my experience it takes a degree of emotional sophistication on the part of both of the partners and the therapist. I have had the most intense counter-transferential feelings while working with couples, but I think I have been able to utilize my psychoanalytic training the most in those moments with those couples in terms of pausing and examing all the angles before speaking. I think it has been some of the best work I have done as a therapist--but some of the most complex.
Also with adolescents, I always see the young person first to see what is going on with them and the family, if they are taking the meds, and in the initial interview if they even want to be there and then I bring the parent in at the end for a kind of "wrap up" to re-empower the parent and get family history and explain/get consent for medications. I also will sometimes recommend family therapy at some point during one of these wrap ups and how children feel so supported when the whole family comes together to discuss changes that can be made to improve the entire family's well being. I do what ever I can to avoid having the child feel like or be made the "identified patient" in a famility system that is dysfunctional, usually to put it mildly....
My program emphasized a lot of family systems therapy and this has stood me in good stead.

Sophia said...

I have no desire to do family therapy outside of psychoeducational sessions. I have a third wave behavioral bent, and I prefer individual work.

I don't doubt that family therapy has its place, but I want no part of it. Family systems theories make me want to pull my hair out, squabbling spouses make me want to pull my hair out, and parents who won't do anything to help their kids get better because it means they have to admit to themselves they royally screwed up makes me want to pull my hair out.

We all have populations we don't want to deal with, and mine is throwing a bunch of family members in a room under the hopes they'll get their crap together. I've worked with sex offenders, men charged with domestic violence (Just the men, no couple involvement), murderers, personality challenges, and I've found that I enjoy the clients very much. Families? Ugh.

Elbee said...

I like the idea of bringing someone to therapy, but have had some really bad experiences with this. In a somewhat funny incident in childhood, the three of us children had a family (group) therapist. She had a way of looking toward whoever was speaking with exaggerated interest and raising her eyebrows. In an unfortunate event, my Dad attended one of the sessions (he was an angry type at times) and promptly told the therapist "the kids call you Mrs. Eyebrows!" True, we did. But really we could not have been more mortified.

I also had a shrink who I didn't particulary like and my siblings wanted to come to see him because they were concerned about me. That situation totally blew up and they took the shrink's "side" and it affected my relationship with the siblings for awhile. Really bad idea.