In this chapter I am dealing with issues which I know some readers will find painful, and perhaps would rather not know about. On the other hand, other readers, who have encountered the illnesses that I will describe, will be thinking that it’s about time that someone wrote about them. I will be referring first to physical illnesses, and then to psychiatric illnesses, psychological problems and problem drinking, with advice about how to cope with them as a couple. Indeed in some cases the illness may bring the couple closer together than they were in health, and reveal to both of them strengths that they were not aware of. In any case, I feel that it is better for us to think about these problems in advance, so as not to be completely bowled over if something then happens which we have to cope with as an emergency.
The couple relationship is of course one which can be highly satisfying and can provide a lifelong support system for both partners and their children. However, there is always the risk that sooner or later one or the other will fall ill, more commonly in later life, and this usually has to be dealt with primarily by the partner who remains well. Whatever the illness, this partner will have to take on more responsibilities, and there will also be a change in the balance of power in the relationship. These are some of the long-term physical illnesses which can result in stress on the partner:
• Heart disease (especially coronary disease)
• Cancer
• Diabetes and other metabolic disorders
• Kidney disease (including renal dialysis and transplants)
• Physical disabilities (including wheelchair cases)
• Neurological diseases (e.g. multiple sclerosis and strokes)
• Epilepsy
• Problems after surgery and accidents
It is often tempting for the well partner (the carer) to take over completely in these circumstances, but that isn’t necessarily the best route to take. The ill partner should be encouraged to do as much for themselves and for the other partner as they reasonably can, to give them a better self-image and to reduce the burden on the carer. The couple should try to form a ‘health alliance’ to find out as much as they can about the illness, and combine forces to get the best out of the health services. There are also support groups that can be accessed by them to help the ill partner to meet others with the condition, and the carer to meet other carers. It is also helpful (depending on their ages) to keep children informed about the illness and its possible consequences, so that the developments don’t come as a surprise to them.
All of these illnesses affect not only the sufferers themselves but also their partners and other family members. There is not a great deal of research on the effects of illness on partners and families, but in my clinical experience a partner’s illness can have quite severe repercussions, including depression in the ‘well’ partner. The response of the partner is a significant factor both in how the sufferer copes with the illness and how the family as a whole responds to the stress of the situation.
Both the patient and the partner/carer have to accept the reality of the illness, and take a realistic view of what the future condition of the patient is likely to be. This may take time, and it is important that the partners talk about the problems on a fairly regular basis, with input from their doctors or surgeons. It is also helpful to be able to discuss the illness with friends and relatives, so as not to hide it under a cloud of secrecy.
The aim should always be to encourage the ill person to be a fully participating partner in couple and family life, as long as their health allows it. Both they and the partner have to be constantly aware of the changing situation as the illness progresses, and at every stage reach the best adjustment in terms of what each partner contributes.
Some partners can become quite stressed by the illness and the extra burdens that they have to take on as a result. Here the ill partner can have a role to play in reassuring the well one that they are doing all that can be done under the difficult circumstances that they face. Doctors, surgeons and healthcare workers are gradually becoming more aware of the stresses that partners face, and will in some cases provide or arrange counselling for them.
Similar problems face the partners of those who suffer psychiatric illnesses, and here there is a further stress in that the illnesses carry a stigma, which means they may not be understood by friends, relatives or neighbours. Most families have encountered psychiatric problems, either in one of their own relatives or in friends or neighbours. The more common psychiatric illnesses include:
• Schizophrenia and other paranoid states
• Manic depressive disorder
• Dementia (Alzheimer’s disease)
• The effects of brain injuries and strokes
• Depression and anxiety
The effects of dementia and brain injuries are rather similar to those of other long-term psychiatric illnesses, so I will not expand on them at this stage. I will deal in some detail with depression, schizophrenia and manic depressive illness, for which there are more specific problems for the partner, but also specific solutions that they can use to alleviate the difficulties in the relationship. I will then go on to mention a number of similar conditions which can affect the relationship.
It is always best to work together to get medical help, including medication, as soon as possible. There is effective medication available for many of the illnesses, and in addition this can be supplemented by some well-tried methods which the relatives and partners can use to help the sufferer to overcome their disorder and live a more normal life (see below). The most useful message that the sufferer and their partner can hear is that, whatever the illness, it is possible to get over the problems and have a reasonably satisfying life in spite of it. It is also helpful to think of the sufferer not as ‘a schizophrenic’ or ‘a depressive’, but as someone who suffers from schizophrenia or depression. This reminds us that the sufferer is firstly a human being and secondly an ill person, and hopefully increases the chances that they will be able to live a more normal life.
Whenever someone becomes psychiatrically ill there is a disturbance in the balance within their relationship. The person who is ill or stressed, like someone who is physically ill, has to some extent become weaker or more vulnerable than they were before, and often their partner or another relative has to take over some of their duties and responsibilities. If the person who is ill recognizes that they have a problem, it is easier to cope with this transition, but if they have no ‘insight’ it becomes more difficult, and may lead to disputes about how much they can be trusted to do.
Depression is a very common problem, and almost always affects the partner as well as the sufferer. Often the depressed partner experiences a loss of self-esteem and confidence. The well partner, as in a physical illness, has to take over some of the responsibilities of the ill partner, and may have to take care of them if they are in any way dangerous to themselves.
Depression should be taken seriously, and the depressed person should be encouraged, if the problem persists for long, to consult their doctor and if necessary get referred to a hospital for treatment which should include medication and/or psychological therapy. Cognitive behavioral therapy, psychodynamic therapy or couple relationship therapy have all been shown to help patients with depression. There is also the possibility of self-help treatment using cognitive behavioral techniques as described in another book in this series, Overcoming Depression by Paul Gilbert, and it would be sensible for both partners firstly to try to apply some of the ideas in that book within the relationship. These include pinpointing ‘triggering’ events, feelings or images that may lead to depressed thinking, and challenging the negative thoughts that result. It would then still be possible to go for more formal therapy if this was thought to be necessary.
The depressed person is generally more than usually sensitive to criticism, and the well partner may have to be careful what they say. This doesn’t mean that argument is necessarily a bad thing, but the well partner has to be more circumspect in an argument, realizing that the ‘ill’ partner may be hypersensitive in many areas of life compared with the way they were before the depression started.
It often seems that a vicious cycle develops in depression, in that the patient becomes inactive, perhaps having to be off work or otherwise missing out on normal activities. It can improve matters if they can be encouraged to do more things, even if sometimes they don’t seem to want to. A diary of daily activities can help to show if progress is being made, and both partners can monitor how things are improving. Simple exercise can also be helpful in increasing fitness and improving morale.
Often a depressed person is less interested in sex than before, and the partner should be aware of this. It may cause conflict, but it may be possible to deal with it (as I suggested in Chapter 7) by discussion, by setting up a timetable or by agreeing on a temporary pause in this side of the relationship. In some cases the depressed partner’s sex drive is not actually reduced at all, but the well partner may think that it would be wrong to raise the topic, and in that case an open and sympathetic discussion may resolve the issue.
In some couples, however, the depression is not the primary problem, but more of a reaction to difficulties in communication. The partner designated as the ‘patient’ may have slipped into a passive and withdrawn way of reacting to a dominant and possibly intrusive partner (see Chapter 6), and may therefore seem to be showing signs of depression. It is always worth asking the question as to whether the ‘depression’ gets worse when the couple are together, and if so whether they could do anything to alter it by treating each other differently. If you find yourself in this situation, it is well worth having a timed discussion with an agenda to see whether the non-depressed partner is doing anything to make the depression worse, because they could then do something to improve it.
Case example
Jane (38) and Joseph (40) had been married for 20 years, with a 16-year-old son. The original presenting problem was that Jane, an active and go-ahead marketing executive, had been suffering from stress and depression the past two years, although she had benefited from cognitive therapy. One of her main worries, however, was that Joseph was ‘stuck in a rut’ in his work (as a self-employed antique dealer) and that he was ‘deeply depressed’ about it. She spent much of her time worrying about him and thinking about how he could improve his situation, and had drawn up several action plans, all of which he rejected as being unrealistic. In couple therapy it emerged that his ‘depressions’ were not as severe as she thought, and a helpful intervention was when the therapist suggested that she should stop worrying about him, and that his ‘bad days’ were not the result of depression but of his perfectionistic personality and the current trough in the market. She became more relaxed about the situation, and the tensions between them decreased considerably as a result. Joseph never took antidepressants, but his attitude to his problems became more optimistic as Jane took less notice of them. Her depression was relieved by the reduction in the marital tensions and her own cognitive therapy.
Antidepressant drugs are often very helpful in treating depression, although they are not actually ‘happiness pills’. They act more as a kind of ‘extra skin’ psychologically, enabling the patient to accept the stresses and disappointments of life without getting too upset about them. They control the condition rather than curing it, but episodes of depression are in any case often fairly short-lasting, and some patients should be able to manage without medication fairly soon after starting it.
There are also now a number of clinics in which it is possible to obtain cognitive behavioral therapy, couple therapy or psychodynamic psychotherapy for depression. You might think of this if you prefer not to take medication, if you have had a poor response to it, or if the depression seems to have gone on for a long time. The methods used are clinically proven, and may produce results which are longer-lasting than the effects of antidepressants.
In a short self-help book I am not intending to give a lot of space to these more serious mental illnesses. However, I feel that knowing something about the way that couple therapy can help these disorders might be useful to you in dealing with more everyday problems in your partner.
This is a condition which typically starts in the teens or twenties and can either run a variable course with periods of illness and periods of being well, or may result in a long-term illness which lasts for life. There are many types of symptom, but in most cases the patient has false beliefs (delusions), often of a persecutory or grandiose nature, and may also hear voices. With the help of medication the illness can be made much milder, but it is unusual for a complete cure to take place.
Schizophrenia obviously affects the relationship quite radically. The first crisis is usually that of admission to the hospital. Here the patient may not be aware (‘lack of insight’) that they have an illness, and may want to act on the delusions, perhaps doing things that endanger themselves or others. In the face of this irresponsible behaviour, the nearest relative (often the partner) has to make the decision to bring in the doctor and social worker to see whether the patient needs to be hospitalized against their will. This of course has a huge impact on the relationship, and the partners may not find it easy after this to rebuild it. The professional team will certainly take this into account, and make it clear to the patient and partner what the consequences will be.
Here we enter the world of rehabilitation, in which the ill partner is helped to readjust to outside life following a breakdown. Research has shown that in schizophrenia the chances of a good recovery and a future free of further breakdowns are increased by the patient taking their medication regularly. They are further helped if the partner (or nearest relative) is calm, quiet and low-key in their approach to the patient, rather than enthusiastic or pushy. It also helps if the patient has (as in the case of depression above) some interesting and rewarding activity during the day. If they can return to their old job this is ideal, but there are some patients who are too ill to do so, and regrettably there are still some employers who are reluctant to have the patient back following a breakdown. Even if they cannot return to work, it is a good idea for them to be out and about for some time every day, to keep from getting too stuck in the rather inactive way of life that the illness sometimes causes such patients to lead. This also prevents them from being in too close contact with their partner, which is not good for either of them (the recommendation is that the patient doesn’t spend more than 35 hours per week in face-to-face contact with the nearest relative or carer). In the longer term it is quite possible for the ill partner to return to something like equality within the relationship, and again it helps if they can find an area they can take the lead in, for example gardening or helping the children with homework.
This is a much more variable illness than schizophrenia, and the breakdowns are usually fairly short-lasting, taking the form of either severe depressive episodes, with suicidal ideas, or manic behaviour, with grandiose ideas and impulsiveness. In either of these states the patient may need to be hospitalized against their will (see above), because of the danger to themselves or others, but the periods of illness will usually resolve quite quickly, and there are long periods of normality between them. There is a range of effective medications which can both damp down the severity of the manic behaviour and depressive episodes and protect against recurrences. The role of the partner is to remain vigilant for the early signs of a breakdown, to ensure rapid treatment if one occurs and to protect the patient and family from any danger resulting from the illness.
There are a number of problems which can affect individuals and can have a strong influence on the relationship, but which are not necessarily defined as psychiatric. These include general anxieties and worries, which can cause considerable stress to the partner because of the need to reassure the worrying partner or to reason with them about their fears. The same kind of pressure can be felt by one partner when the other one is suffering from work stress and is bringing this home to the partner. Generally the response to this should be to discuss the situation, possibly on a timed basis, and see if any solution can be found to the stresses themselves. In this process the couple may be more effective working as a team than either of them individually.
This is a problem which is especially relevant to couple relationships, because the jealous ideas actually centre around the partner. It may involve repeated interrogation about who the partner has been meeting, and even detective work such as phoning the partner unexpectedly, questioning their friends and searching their belongings. The jealousy may of course be delusional, part of a paranoid psychosis akin to schizophrenia. In this situation there may be some degree of danger to the partner, and the solution may have to involve either separation of the partners or psychiatric treatment, or both. However, the more common kind of jealousy, which is more like an exaggeration of the normal possessiveness within couples (see Chapter 4), may be associated with mild depression, with insecurity, with alcoholism (see below) or with stress. Here it is possible to use couple therapy to help the problem, and in some cases the problem may be able to be dealt with on a self-help basis, as I will show in the next section.
Very often jealousy is based on a misunderstanding between the two partners, for example if the non-jealous partner does things innocently, like being friendly with colleagues, which the jealous partner misinterprets as indicating infidelity. If it becomes clear that this is so, a timed discussion session (see Chapter 5) may give the couple the possibility of increasing their empathy for each other, to the extent that the springs of the jealousy are no longer so powerful. Knowing how the problem arises, the non-jealous partner may be able to reduce their natural sociability or flirtatiousness out of respect for the sensitivities of the jealous partner, and so control the problem.
If it is not possible to change the situation by improved communication and changed behaviour, more creative solutions may have to be sought. The jealousy timetable is something which we developed in our couple therapy clinic, and it is based on the idea that jealous accusations may be difficult to suppress, but they can be made bearable if they can be contained. So, if the jealous partner can’t stop the accusations and the interrogation, it may still be possible to keep them under control if you agree to speak together openly about the issue, with full cooperation on both sides, but only at a specified time each day. The exercise below will make it clearer how you should go about it. A similar approach may be used for other types of behaviour in one partner (for example, complaining about the partner in a repetitive way – see Chapter 6) which are difficult to stop doing and which the partner finds unbearable. The timetable should give the complaining partner a chance to have the other’s full attention during the specified time, and the other partner will be reassured that they don’t have to put up with it all day.
Exercise
The jealousy timetable
• Recognize that the jealous partner needs to talk about their jealous thoughts from time to time
• The jealous partner should recognize that when this happens it is painful and difficult for the other partner
• You should then agree on how much time it is reasonable to spend talking about these ideas – a good compromise might be once a day for 30 minutes
• You should plan to sit down with the timer going and no distractions for 30 minutes once a day at a planned time (e.g. 9 p.m.), and you will then talk about nothing else but the jealous ideas
• During this time the non-jealous partner will give the other one his/her full attention and answer all questions
• If the subject of jealousy comes up at any other time earlier in the day, the non-jealous partner should say ‘I can’t discuss that now but we have 30 minutes at 9 p.m. and we will deal with it fully at that time’
Again, if this is not successful it would be worth seeking either counselling as a couple or individual therapy for the jealous individual.
These are problems which have a profound influence on the relationship, and the partner will usually be well aware of the need for treatment. However, the drug or alcohol user needs to be motivated to seek treatment, and in many cases they are not even convinced that they have a problem. Treatment can’t be forced on an unwilling patient.
Alcohol can be a very good social lubricant, and many couples first meet in a situation in which alcohol is being served, such as at a bar or a party. It can also in small doses be quite helpful in reducing inhibitions and helping those with sexual problems (see Chapter 7). However, alcoholism (by which I mean drinking to excess, with or without a true state of addiction) is a common problem, more so in men than in women, affecting perhaps 5% of the population in the West. Alcoholism can have a devastating affect on the relationship and on family life. Intoxication with alcohol has several different effects on the relationship:
• It makes the drinking partner more impatient, demanding and insensitive
• It leaves the non-drinking partner with the responsibility of dealing with an unpredictable situation
• It costs money, which usually comes from the family accounts
• The drinking partner may be sexually demanding but unable to perform
• The drinking partner may become violent (see Chapter 9)
• The non-drinking partner is likely to become resentful and reject the drinker
This sometimes leads to a very unequal kind of relationship, with the drinker taking the role of the irresponsible sinner and the other partner the role of the saint. In extreme cases, the drinker is hardly aware of anything outside his or her need for the next drink, and then the couple relationship takes a very low priority in their thinking.
The problems raised by alcohol are complex, and it is often hard to solve them by self-help couple work on its own. The only exception is in those couples where the drinking is at a fairly early stage, and one partner is on the border of problem drinking rather than being alcoholic. There is still some control over the drinking, and the drinking partner may be drinking mainly in response to strains in the relationship. You may in this situation decide that you can get together to have a timed discussion of the problems and work out what the particular areas of stress might be that are contributing to the problem. However, in your negotiations it is better to use ordinary everyday tasks, such as help with the children or coming home on time, rather than tackling directly the more sensitive issue of drinking. By this means it may be possible to improve the general relationship to the point that it is possible for the drinker to control their drinking.
When drinking gets so extreme that the drinker is hiding bottles, drinking in the mornings to start the day and having periods of amnesia when drunk, there is obviously a problem which is too severe to be solved by couple discussions. There is only one way out in the end, and this is for the drinker to receive help to achieve abstinence (since unfortunately ‘social drinking’ as an option is only successful in about 5% of those who try to cope with alcoholism in this way). This help may be provided by Alcoholics Anonymous, with the well known ‘twelve step’ programme for achieving abstinence, or it may be obtained through the various public or private clinics which offer ‘drying out’ treatments followed by help with maintaining abstinence. There is also help for partners and relatives of alcoholics from Alanon, and the organization Children of Alcoholics offers help to those whose parents are problem drinkers.
The problems posed by drug abuse are in some ways similar to those which arise from alcohol abuse, but depending on the particular drug being used the results may differ. Mild degrees of addiction can be triggered and maintained by problems in the relationship, and couple discussions can sometimes help. More severe addiction, however, will, like alcoholism, take over the user’s whole life, and there is little that can be done besides enrolling in a drug withdrawal and treatment programme, either through a clinic or an organization like Narcotics Anonymous.
• Marijuana smoking is often done on a social basis, with both partners involved. It can, however, sometimes reach problem proportions, with the user being almost permanently under the influence of the drug, and possibly suffering from paranoid ideas as a result. Then it needs more than a discussion as a couple to resolve the problems, and drug addiction programmes may be needed.
• Drugs like heroin, which lead to sedation when they are used and severe withdrawal symptoms when the user is deprived of them (known as going ‘cold turkey’), cause a great deal of disruption in the relationship; and the user, like the extreme alcoholic, is thinking most of the time about how to get the next ‘fix’. Again, this causes great disruption to the relationship, but there is little that can be done about the drug habit without professional help.
• Cocaine, like Marijuana, is a drug which can be used socially, but especially in its ‘crack’ form it becomes very addictive, and the user, as with alcohol or heroin, lives for nothing but the next dose of crack. The partner is of course severely affected by the drug habit, but can do little about it without the help of a professional drug clinic or treatment service.
When a partner is physically ill, psychiatrically ill, psychologically disturbed or has a substance abuse problem, there is always a degree of stress on the other partner, who has to take a great degree of extra responsibility. The helping professions have been a bit slow to recognize the pressures that partners may be under. The good news is that sometimes it is possible for a couple with one of the partners unwell to do something to alleviate the stresses, and thereby perhaps to hasten recovery from the problem, or, if it is not treatable, to make it easier to cope with. The situation may actually lead to a strengthening of the bond between the couple and help them to grow as individuals.
• Illnesses in one partner are very common.
• They affect the other partner, sometimes even more than the ill one.
• It is best to try to give the ill partner the chance to live as normal a life as possible.
• The couple should work together to find out as much as they can about the illness.
• Social stigma causes more difficulties with psychiatric or addiction problems than with physical illnesses.
• There is much that both partners can do to alleviate the stress of illness, to cope with it more effectively and live a satisfying life in spite of it.