As a follow up to the post about creative/productive depression, I think it’s important to also address the question of depression as it might affect couples therapy, not just individual therapy.
Depression case example
This presents in the form of one “depressed” (“D”) partner who has some combination of lethargy, unresponsiveness, passivity or hopelessness, sometimes with irritability, about the relationship. Let’s assume that D has been out of work for a while and is drinking too much wine. The other “non-depressed” (“ND”) higher functioning partner often responds to this in a solicitous and caring way, a correspondingly helpless or frustrated position, or both. D and ND have become emotionally fused, making for a difficult, slow beginning to therapy. And, when beginning therapy, these clients often want immediate therapeutic progress to revive their hopes at a low and vulnerable point in time.
Treating Depression With Couples
Peter Kramer, author of “Listening To Prozac“, followed that 1983 bestseller with a book in 1987 that I like very much, “Should You Leave?: A Psychiatrist Explores Intimacy and Autonomy—and the Nature of Advice”. In it, he makes one argument (among many that I think are brilliant*) for a psychiatrist/therapist taking what he calls an “essentialist” position, in which the depression, not the relationship, is the “essential” target for treatment. In most of today’s psychiatry that typically means that medication would be recommended. But I observe that many clients are philosophically opposed to meds, and will not use them solely on a therapist or doctor’s recommendation. A professional, whether it’s me or someone vastly more talented like Dr. Kramer, might have psychotherapy alone as the means to help these clients.
Depression As ‘Loss Of Self’
He conceptualizes depression as a “loss of self”, and re-gaining that sense of self will help make a couples therapy with real forward drive. I think his conceptualization could work out well enough in therapy. But depression can also be persistent, resistant to treatment, or be dysthymic. The therapeutic challenge for the couple and therapist is to develop an effective response together.
Treating ‘Loss of Self’ With A Couple
Kramer’s concept can get translated by therapists into seeing D in individual therapy. I do not typically think like that. Beginning therapy with an individual relationship is less likely to produce a good one with the couple later. The couple doesn’t benefit by getting an “escape hatch” from the productive anxiety* of facing their situation together. And if I see the presenting problem the same way my clients do, in terms of an identified “scapegoat” (D) married to a not-as-responsible partner (ND) – I’m of little use to them, and will have a harder time with them if I ever see things differently in the future. The question is, apart from making a separate referral to a psychiatrist for a medication evaluation, how might I begin couples therapy with D and ND?
A Possible Approach
I might approach Dr. Kramer’s observant, creative idea of “depression-as-loss-of-self” a little differently. It’s possible that if I was “keeping pace” with where my couple is really at, I might suggest that they are both losing self, at least their best or strongest sense of self. Often enough, even nice people can fight a lot over how to “fix” the depression. ND is offering “solutions”, but D isn’t buying them. As a result, D is getting more depressed and “victimized” (believing there’s no good choice but to follow ND’s advice), while ND feels like the good/helpful partner who’s being rudely ignored, and gets easily enraged as a result.
I might ask what D is going to do to create new choices other than what ND is pushing for, or how D might be able to make a specific request for ND’s help, while accepting ND’s right to say “no” to that request. That would mean not taking ND’s positions on “depression”, or being out of work, or drinking, so personally. D might well ask, “How could I possibly not take such matters personally? I might suggest that taking ND’s comments personally seems to be related to not taking the “issues” deadly seriously.
D might retort, “What the hell do you mean – I am taking them seriously!” [D does not look so passive anymore, and the irritability looks shallow.] But if the general pattern is no work and too much wine, I may have to say, “No, you’re not.” D might say, “You’re just taking [ND’s] side!” Actually, I’m trying to form an alliance with D, suggesting that D’s strongest sense of self could accurately call out D’s weakest self a lot better than ND can, and then start really getting effective at change.
I can suggest that ND would then likely mind ND’s own business a lot more. Then, she could feel better without him feeling badly. ND is not sure at this point whether I am taking a sideways shot at her, or supporting her right to lead a life that’s less about being a rescuer (a “helper minus a clear agreement for helping”). ND’s uncertainty about my stance toward her is OK with me – I believe I am challenging her to be at her best too, by not taking my interventions personally. I would offer to help D with what “really effective” looks like, and how soon “‘effective’ will take effect”, and that might be a process ND could pay real attention to instead of re-enacting the “frustrated rescuer” one more time.
This is of course an imaginary therapy session, slightly in the vein of Dr. Kramer’s fictional discussions with his fictional supervisor in “Should You Leave…?” Obviously, many complicating factors in D and ND’s life are left out of the scenario. I am only trying to answer my own question about how I might work these clients together, as a couple. I don’t treat D as fragile, and I don’t treat ND as “higher functioning.” I treat each partner as a person who wants autonomy and success, and might be willing to change to get a little more of both, while staying together and behaving more decently and responsibly toward each other and themselves.
If either or both want to take meds to help them through this rough time, my general stance is “go ahead” – whatever helps you be your best.
* Kramer does indeed explore the issue of ‘giving advice’, but well beyond that, he’s written one of the wiser books a therapist might read on a number of subjects. Dr. Kramer is well trained in psychoanalytic practice, but also knowledgeable about the most rigorous of family systems theorists and clinicians, Murray Bowen, M.D., whose work has also been influential for me. Kramer does a very nice job bridging analytic, systems and psychiatric (including medication management) thought and practice. I can assure the readers of this blog that connecting these areas is quite an accomplishment. Kramer represents the phrase, “The better the therapist, the more different therapies look alike”