Couples therapy & Mental Illness

Jess says, "I want him to be more understanding of my mental illness."  I ask, "What do you want him to understand?"  Jess: "How to talk to me when I am upset so that I will calm down."  I ask Steve, "What does Jess look like when she is upset?"  Steve hesitates.  He doesn't know how much it is okay for him to say.  "She can't stop moving.  She walks all over the house for hours.  She's talking, talking, talking." Jess says: "I know I talk a lot but I just want him to tell me its going to be okay.  I know I get intense when I am upset but I don't think its that bad.  Steve: "She talks super fast for hours at a time, till three in the morning.  And I have tried touching her, she doesn't want to be touched. Everything I say is wrong. She's super irritable.  She screams at me, sometime she throws things.  Hits me."  I say: "That doesn't sound like you were upset.  That sounds manic.  Or maybe a mixed depressed-manic.  I don't think a anybody -- the best trained psychiatrist or nurse -- could talk to you in a way that would calm you down when that's going on.  I understand that you want him to soothe you, to make it better in those moments but I don't think he can." (This couple is a composite of many couples I have seen).   

People with mental illnesses can have problems in their relationships just like other people.  (For my thoughts on the fluid and ever-expanding definition of mental illness, see here and here).  But serious mental illness impacts on couples work in a few ways that can tell us some interesting things about all of us. 

The first time I worked with a couple immediately after one of them was discharged from psychiatry, I spoke to the treating psychiatrist about trying to help the couple re-establish some sense of intimacy.  He said something very wise. "Sometimes people who have psychotic disorders can't stand too much intimacy."  Intimacy is the bread-and-butter of couples therapists, whatever our orientation.  Help people feel a little safer, a little better heard and they will feel closer and more connected to their partners.  For people who have had the integrity of their sense of self fall apart, being connected with another person can be an existential threat.  It may be a human drive to connect with others, but it can also be something that threatens our psychological wholeness, not a small consideration if you believe your psychological wholeness is fragile. 

Like just about everyone, the mentally ill want their partner to complete or heal the parts of themselves that are broken.  Jess, in the composite above, wants her partner to keep her from being sick.  A lot of people with mental illness who I have seen, want this from their partner, whether they articulate it or not.  They long for their partner to save them from this serious and frightening condition.  Cognitively they may know that it isn't realistic but they want it so strongly that it can be very hard for the relationship.  Sometimes it can turn to blaming the not-mentally-ill partner for things way outside his/her control.  This is tricky: stresses in relationships, hurts and frustrations, neglect and emotional abandonment, not to mention outright abuse can be very psychologically destructive.  For someone with a mental illness, a cruel partner can make things worse.  But I am clear with both partners that a loving supportive partner can't heal a mental illness, and a garden-variety jerk can't cause it.  Mentally ill people need to take responsibility for getting appropriate care (for how difficult this has become see here).  

I once saw a woman in psychiatry who was recovering from an episode of psychosis that had been induced by a side-effect of a medication.  She was afraid about how she would remember the episode.  She was worried that she would be humiliated, frightened and ashamed by how she had acted.  I told her that in my experience many people don't remember episodes of psychosis very well.  Like a bad dream, psychotic episodes are vivid and intense at the time and often evanescent afterwards (in particular if they are ego-dystonic, that is if they experienced it as troubling and contrary to their usually sense of self).  I have seen this with mania as well.  People are often amazed and doubtful about the descriptions of their friends and relatives about how they acted after the fact.  I think this is a tremendous mercy that our minds show us in regards to these unusual mental states, that they can be forgotten or minimized.  It can be very adaptive.  However, it can be very painful and destructive for a relationship.  A client says, "We can't talk about what he is doing when he is acting really crazy because there's no talking at that moment, and we can't talk afterwards because he doesn't think it was that big a deal and its mean to rub his nose in it." 

There's a really neat blog post by Rebecca Jorgenson summarizing a study about attachment style, memory and conflict. 

The results were clear. Clients with Avoidant Attachment Styles, those who when feeling threatened manage distress through emotional distance and acting independently from their partners, and who withdraw under threat, were far more likely to remember the distressing conversations in a way that matched their autonomous reactivity. The avoidant partner remembered being far more clear and assertive than they actually were.

People who manage distress through emotional distance from a partner are more likely to cognitively distort their memory of their arguments. 

We all have a fragility of the sense of self.  We all seek to protect ourselves from the hurt a loved one can cause.  We all look back at arguments and paint ourselves as a little calmer and a little more patient than we were because recognizing that we were irrational is so painful.  These are human ways of being in a couple that can be magnified when mental-illness is part of the picture.  People with mental illnesses deserve couples therapy that takes them seriously as people, and part of that is taking seriously the impact their illness has on them and their partners.