TRANSCRIPT OF AUDIO FILE:

BEGIN TRANSCRIPT:

THERAPIST: Hi, come on in (inaudible). (pause) Hi.

CLIENT: Hello.

THERAPIST: I'm glad you could make this time.

CLIENT: Thanks. Thank you for having me.

THERAPIST: Sure.

CLIENT: I'm a little I want to be a little cautious not to disturb the balance of you treating our relationship.

THERAPIST: Mmmm-hmmm.

CLIENT: But I think it's good to come this time.

THERAPIST: Yeah, I respect that. You know, I think I said from the start, typically I meet with people together and it's the relationship that I focus on. I feel like these are kind of exigent circumstances -

CLIENT: (chuckles)

THERAPIST: where there's a lot of crisis and stress. So, you know, I'm just trying to kind of respond to the needs of the two of you and sort of sort it out from there.

[00:01:10]

CLIENT: I appreciate that.

THERAPIST: If that makes sense.

CLIENT: It does, yeah. I certainly trust your judgment in the matter. I just wanted to voice my hesitation.

THERAPIST: Mmmm-hmmm. (pause) So what's going on?

CLIENT: Tanya is in the hospital again. She's in Frederick this time which is, in theory, very good. It seems to mostly have lived up to its reputation, so that's good also. She started ECT on Monday which is (pause) in some sense a scary treatment. Let's shock you until you seize and then repeat that several times a week for several weeks. But I don't know if that's actually any more scary than the medications that are administered or have been administered over the last year.

THERAPIST: Mmmm-hmmm.

[00:02:02]

CLIENT: It seemed to go okay, no major adverse effects. Headache and so forth seemed to come from the muscle relaxant that goes with the treatment. (pause) I think we're both (pause) scared that they'll decide she's better and release her and she won't really be better. Sure, she'll be better in the moment and present better but then come right back and all of the stresses are still there. She still will be unemployed when she comes back out, presumably. There's no clear reason why she wouldn't just end up right back in the same place. But the more times we test her will to live, the more likely we are to find the actual breaking point. (pause)

[00:03:00]

She's been talking with her treatment team, inpatient, to avoid that happening. So they're talking about keeping her for longer or putting her into a residential program there. I think that would be good. (pause) We went in Wednesday night. You saw us Wednesday.

THERAPIST: Yeah, I mean it was what happened because you guys, and Tanya in particular, said she was feeling better. So what happened from when you met with us met with me to later?

CLIENT: It was literally all internal. (pause) They don't know other than she got to the point where she wanted to kill herself, and she called Chad and they talked and he said "I've really " having talked to her 30 or 40 different times in crisis, he doesn't send her to the hospital every time, but this time he said "No, I think we need to send you in."

[00:04:04]

I'm a little bit at a loss to say exactly what happened other than (pause) some combination of the stress of being unemployed and the idea of looking for jobs again and feeling like no one was ever going to hire her. And that that just meant that the world had finally recognized her fundamental worthlessness or something. I think those things and she had decided during the vacation that she would be fine for the vacation, and I don't know to what extent coming back and the vacation being over and her not having decided something similar for the next several days I don't know how that plays into it.

THERAPIST: Mmmm-hmmm.

CLIENT: (pause) So I guess that's what seems to have happened.

THERAPIST: Mmmm-hmmm. So your sense was she was very distressed. She was more just keeping it to herself, or that there's just a rapid change in what progressed during the day?

[00:05:04]

CLIENT: My sense was that there was a rapid change. I don't know whether that's true or not, but that was what I thought was going on. (pause) And I don't know exactly what she would say. I think she would say that it was a rapid change, but she'll often say that (pause) she's always more or less bad and that it only becomes apparent at a certain point. So it appears to be sudden, but it's not. I don't know how much to trust that because when she's at her worst, she can't remember ever having not been bad. So there's a real bias in the self-reporting there. I don't know what's true and what just seems true to her at the time.

THERAPIST: I imagine this has affected you pretty deeply.

CLIENT: (chuckles) Yeah, that's about right. (pause) Yeah, so we took her in at like 11:30 Wednesday night, so we were there until 3:30 in the morning.

[00:06:08]

Then they figured out they had a bed for her at Frederick and they would take her in the morning. So I went home at that time. But my sleeping schedule has been somewhat disrupted ever since. I have not really been getting any work done. I've been visiting her in the hospital. (pause) You know, I'm scared. (pause) I feel alone. (pause) I've been keeping in fairly good touch with both her family and with my family, which has been good and helpful, but it's not exactly the same. She fills a particular spot in my life and just isn't there. So it's hard.

[00:07:01]

THERAPIST: So alone and feeling the further loss of her.

CLIENT: Yeah, yeah.

THERAPIST: Right. It's very good that you have support. But she does, as all spouses do, you know, fill a unique place in people's lives.

CLIENT: Right. (pause) Which is kind of the point of having a spouse.

THERAPIST: It is the point of having a spouse.

CLIENT: (chuckles)

THERAPIST: When something happens in different ways that things can happen to a person, it's very challenging.

CLIENT: (pause) Yeah.

THERAPIST: (pause) In what way did you know, I want to know more about in what way you felt that coming here, given that the way I presented couple's therapy is both people in the room, so I appreciate I presented that too but in what way do you feel coming here would upset the balance? (long pause)

[00:08:22]

CLIENT: There's both upsetting some actual balance in the way you treat, which I really don't think there would be much of. Again, I really do trust you to be able to do your job. (pause) From our end, you've done it very well so far, so I have no reason to question that.

THERAPIST: Mmmm-hmmm.

CLIENT: But certainly I have one presentation of information and Tanya has another, so if you're only hearing mine repeatedly, that changes the distribution of information in your total pool or something. But then there's also the appearance of it changing things. So if I've come to you a whole lot of times and Tanya has not, or Tanya and I have together come a similar number of times, it has the possibility, I think, of appearing to Tanya as if (pause)

[00:09:32]

Or I am concerned that it might have the possibility of appearing to Tanya that you and I would gang up on her or something. Not that I really think that you would do that but -

THERAPIST: Right. Well, certainly, I mean that's, you know, in general one of the reasons that I don't meet with one person individually and not the other is, you know, the feeling of kind of being unbiased. That clearly my alliance is to both of you and not one of you, so that's certainly true.

So when she comes back, I certainly want to check in with her to see what that's like. I certainly don't want her to feel left out. You know, I guess what I've been thinking about, and I want to think about it more, in part you know, the situation changes, so I need to wrap my mind around what part of it is sort of unpredictable and what part of it may become more of a routine in some way.

[00:10:24]

But, you know, this is unconventional couples' therapy at the moment because usually it's about two people engaging in how to work on the relationship. When one person is so distressed or impaired, it makes things it makes it more challenging to think about what we're doing together. Not to say that we can't do something very productive together, but it's sort of I need to think outside the box a little bit in terms of how I can help you. I'm very appreciative of your perspective that, you know, obviously we meet half the time and the three of us meet half the time and that seems kind of odd (chuckles) -

CLIENT: Right.

THERAPIST: as an ongoing method. And it could be, you know, I mean I very much felt that I wanted to reach out to you today, especially in the context of things having gone better and then things are terrible, and I know you're not seeing someone individually. So I kind of felt like what's the harm and at least touching base and seeing how things are going for you.

CLIENT: I appreciate that.

THERAPIST: Yeah, so that was my perspective. And I have to think like, you know, maybe until Tanya gets a little bit better on her feet, does it make sense for us to proceed, the three of us, especially if she's going to be in and out of places where she can't even be here, you know?

[00:11:31]

CLIENT: Right.

THERAPIST: So does it make sense to I mean, naturally it's going to be put on hold for the time being while she's in the hospital.

CLIENT: Sure.

THERAPIST: So, I mean, that's one question I have. The other question I have, I feel like part of what I'm doing is trying to have a sort of stop-gap measure so you have a place to talk. And so the question is maybe do you want to find a place to talk with someone, even just about the you know, forget about anything else aside from just the stress of having a wife who is in and out of inpatient units who is suicidal, which is an extremely stressful situation.

CLIENT: Right.

THERAPIST: And I do think that talking to someone does it's not going to completely rid it, but I think it might mitigate the feeling of being alone.

CLIENT: (pause) I mean, I can definitely say that talking to people helps. Like I said, I've been talking to my family and to Tanya's sister and to my friend Franco. Talking about it helps.

[00:12:31]

So yes, it probably does make sense. (long pause) I have a lot of logistical hesitation in terms of I need to transition my insurance from being in Ohio to being here in Colorado. That would need to happen before I started seeing someone or in tandem with doing that. (pause) But that's just a hassle. (pause)

[00:13:36]

Then of course there's the problem finding someone who is a good therapeutic match, you know. Those both seem like hurdles of one kind or another, so I'm reluctant but I'm not sure that I shouldn't do it anyway. (pause) If you have any thoughts, I would appreciate it. I'm sort of out of my expertise on it.

THERAPIST: Well, I definitely yeah, I mean, I don't see it seems like you feel comfortable with me, if I'm correct.

CLIENT: Oh, absolutely.

THERAPIST: I don't see why you wouldn't find someone in you know, find someone else you would feel comfortable with.

CLIENT: Okay. I know Tanya has had a number of different treatment professionals that she really has not liked and just have not been the right person for her. (pause)

[00:14:39]

And I guess I have a couple of other friends who have had similar experiences where they go to one or two people who are just not good.

THERAPIST: Mmmm-hmmm. Yeah, there's certainly there are not good therapists -

CLIENT: (chuckles)

THERAPIST: good therapists who, you're right, are just not good for everybody. Yeah, so I'd certainly I mean, the logistical piece with insurance I can't help you with.

CLIENT: No, obviously.

THERAPIST: I mean, that'll be something you'll need to sort out.

CLIENT: I just need to make some phone calls.

THERAPIST: But in terms of finding someone good for you, then that's not -

CLIENT: You don't think that's really a problem?

THERAPIST: No. I know so many good people in this city.

CLIENT: (chuckles) Okay.

THERAPIST: There are really a lot of good people. On a very logistical note, there's a diagnostic code where it's "family therapy without patient," so then I could go through Tanya's insurance.

[00:15:33]

CLIENT: (chuckles) Interesting.

THERAPIST: It's a family -

CLIENT: Right, right.

THERAPIST: therapy code, but the code is that the person who is the patient who it's getting billed under is not present. It's called "family therapy without patient."

CLIENT: Right. Okay.

THERAPIST: I mean, in that logistical sense, I actually think you could probably use that code.

CLIENT: Okay.

THERAPIST: For, you know, on that level.

CLIENT: Thank you.

THERAPIST: Yeah. I think I have to check on that. I don't think I've ever I don't know if I've used that before.

CLIENT: It seems like it wouldn't come up that often.

THERAPIST: Well, when you do parenting work, it does.

CLIENT: Oh really?

THERAPIST: So you might meet with the parent on an ongoing basis and bill under the child -

CLIENT: Okay.

THERAPIST: And the child isn't in the room.

CLIENT: Sure.

THERAPIST: When I meet with people individually when I'm seeing a couple, I always see it as sort of part of the family therapy. I don't see even if the person whose insurance it's under isn't being billed, I think of it as part of family therapy, so that's that piece too.

[00:16:34]

Do you know when is there any projected time that she'll be leaving the hospital or is it up in the air?

CLIENT: It's still up in the air. She's not yesterday she might have been okay for the whole day, I don't know. I mean, she'd been okay up until I visited in the evening. But that would've been the first day where she hadn't really had some acute period of suicidality. Not that she's actually attempting, but thinking very hard about it. (pause) And so I guess she's not really stable at this point, so they need to keep her there until she's -

THERAPIST: (phone ringing) That will go off in a second. I'm sorry.

CLIENT: Okay. That's fine. (pause) So just from the normal treatment standpoint, don't know when the end would be.

[00:17:25]

And then from the point of view of really I'd like for her to be there (pause) long enough that we have some real sense that she will be safe coming back. I'm not sure that's actually possible. I'd like to live in the world that it's possible but aiming towards that, I don't know how long she'll be in.

One distinct possibility is that the ECT will work. It seems to work for 60 or 70 percent of patients for whom medication has not been effective. So since she fits in that category, that's a pretty good number. (pause) And so if that happens, it should start to work by the end of next week or early in the following week. So if it's actually effective, then I think it would not be unreasonable for her to come home then.

[00:18:27]

THERAPIST: So a couple you're looking at a couple of weeks.

CLIENT: Yeah, that's probably right.

THERAPIST: What has it been like with her not around?

CLIENT: (long pause) Well, so in one sense, it's normal because we've lived apart for a long time. In another sense, it's just it's not like being alone itself is what makes me lonely, if that makes sense.

THERAPIST: Mmmm-hmmm.

CLIENT: I like being alone. I don't have a problem with that. But it's the idea that like she's just really not well. (pause) And there's no real guarantee that she's going to get better.

[00:19:27]

And at some point, if she doesn't get better, she will kill herself. There's not really much I can do to stop that. (pause) Just (long pause) So I've been reading a lot. (pause) I've been walking back from Frederick because you take the bus out and it takes and then you walk over from the bus station. So I've been walking back and talking to people on the phone while I walk back. It's a long walk (chuckles) but I like walking.

[00:20:29]

THERAPIST: You walk from the bus or from Frederick?

CLIENT: I walk from the bus to Frederick, and then from Frederick back to my apartment.

THERAPIST: Oh, got it. In Greenbelt.

CLIENT: Yeah.

THERAPIST: You guys are in Andover? That's a long walk.

CLIENT: Yeah.

THERAPIST: It's about five -

CLIENT: Somewhere in there.

THERAPIST: five miles.

CLIENT: Between four and five. It's a good walk. (chuckles) (pause) And, you know, talking to usually kind of a sequence of Tanya's father and then my mother, and then sometimes Tanya's mother and sometimes my father and then usually someone else. Either Tanya's sister or one of my good friends. That's about enough talking for me in a day (chuckles) is that walk. And I get back and have something to eat and read for a while and just can't quite go to bed.

[00:21:33]

So I end up staying up fairly late and then sleeping in fairly late, and then getting up there's a couple hours before it's time to go visit Tanya again, so repeat. (pause) Yeah, sometimes I'm really okay. Sometimes I'm just really sad. It's hard.

THERAPIST: What do you think about when you're sad?

CLIENT: (long pause) I think about the possibility of losing Tanya which, since I like plans, means that my response to my thinking about the possibility of losing her is thinking about what I have to do if I did lose her.

[00:22:44]

And I don't think about that for too long because I just really don't want to. I don't want to have a plan for that situation. I want it to not be on the map of possibilities. Not that I can control that, just it's what I want. (pause) You know, just thinking about it's like I have to make the phone call to Tanya's family or to my family that says that Tanya is back in the hospital, and I don't want to make that other phone call that says that Tanya is dead. I just (long pause)

[00:23:37]

I also think about how I can try to shape, you know, our environment or our lives so that there's something so that it's easier for Tanya to do what she needs to do, and I just don't have anything on that front, so I don't think about that for very long. (pause)

THERAPIST: Well, I know you are really hoping that sort of creating some structure for her or trying to find a context for her to find a job and so forth is something that you're really putting some investment in, and this situation kind of flies in the face of that.

CLIENT: Yeah, that's right. That's right. Trying to keep it, you know, constrained in the sense that her search was very narrow in its focus on teaching type jobs.

[00:24:40]

That is, focused on the things that she thinks that she really wants to do, but also broad enough so that she would have some short-term employment and eventually long-term employment. But I can't do those for her. At least I haven't figured out how to find a job for someone else. (pause) You know, I can't write her statements for her and submit them to an agency. I could, but it's (pause) It's dishonest. It's not a good way to interact with people.

THERAPIST: Well, certainly, I mean I think especially or maybe not especially but the continuation of her being back in the hospital is like sort of changing her environment. It may not necessarily make much of an impact on what's going on for her, at least for now.

[00:25:39]

CLIENT: Oh yeah.

THERAPIST: It's just so much deeper than that.

CLIENT: Yeah. (pause) So then I just don't know what to do. (long pause)

THERAPIST: It's so difficult to be with a spouse or have a spouse who is ill and then when it's this particular kind of illness, I think it's a lot more complicated even than that.

CLIENT: I think that's right. But I don't I mean, I guess she had surgery. (pause) And that was hard, but it was not nearly as hard as this is. Yeah, that seems right.

[00:26:35]

THERAPIST: It was time-limited too, in a sense.

CLIENT: Right, right. Yeah, so I don't know. Is this worse than having cancer? I'm not sure, but I'm not sure (chuckles) Tanya said that while she was in one of the inpatient units, she looked around and she thought about how the people around her were deluded or something like that. You know, at what point do you get to say someone is crazy or not? And she said (chuckles) "Well, I guess I'm on a psych ward, so we're past that point where it's a question." Which was mostly some joking frame, I think. But in this context, we're past the point where we're really comparing who is worse matters.

THERAPIST: Mmmm-hmmm.

CLIENT: But yeah, it's really hard. (pause) She's a person that I have relied on a whole lot in the past and want to rely on, and I need to make decisions like who is going to come visit now.

[00:27:39]

Her family wants to visit, my family wants to visit, but I can't deal with all of them visiting. And Tanya doesn't really want all of them to visit, but then I kind of have to sort out who should visit and who shouldn't and when. And I can leave that to our families to some extent, but there's the important factor of like what is going to be good for Tanya and what is really not going to be good for Tanya. Her mother coming to visit would really not be very helpful right now. Her sister is going to come visit next which will be good. And that's about all we've got planned. But there are decisions that I need to make with Tanya, but Tanya is really not even capable of always giving the input that's needed.

[00:28:32]

Those are little things about kind of the present moment. (pause) I guess I'm struggling with how to rely on her in any sense, and what does that mean for us having a relationship. (pause)

THERAPIST: In that sense, I mean, it's a bizarre apples-and-oranges comparison, but in that sense, having a spouse with cancer is easier because you have assuming it's not brain cancer you have some way of you can rely on them in an emotional sense even if they're suffering. It's a little bit different, actually.

CLIENT: That makes sense.

THERAPIST: Again, it's kind of a horrible comparison. I don't -

[00:29:27]

CLIENT: Yeah, that's okay though. Analogies are useful for whatever. No, that makes sense. Yeah. And that's hard. I don't keep a whole lot of friends. I keep several very close friends and Tanya is one of them. Without her, there's a large piece missing in some way. It's just not I have a different relationship with every person. There's not anyone else to fill that. As we've said, there shouldn't be in some sense, right? She's my spouse. But I don't know what to do with that. (pause)

THERAPIST: I think that's going to take some sort of sorting through and thinking out because that is a big shift. It sounds like it has been somewhat gradual over time that she's been getting more distressed and getting sicker and in some ways getting more suicidal. But it seems like it has sort of hit its well, do you feel like it has hit its lowest point yet?

[00:30:42]

CLIENT: It's sort of it's one of these things that comes and goes. Because she's been up and down for years now, two years now. So when she's well or closer to well, it's not as true. But she's been as bad as she's been for quite a while now and so the longer it goes, the harder it is to rely on her. (pause) But that gets better when she gets better. It gets easier to rely on her again because it's like she's back. But then, you know, it goes away again. So I guess the longer it goes on, even in its cyclic nature, the more it undermines the whole thing. The more I can't trust her sometimes or something, then the more I can't trust her in the average sense or something. (pause)

[00:31:47]

So yeah, maybe I would say it's at its worst now. But it's also always at its worst, like the sense of loss and the sense of (pause) just loneliness are always at their worst, like when she's just been hospitalized because I think they get tangled up in me being afraid that she's not ever going to come back. (pause)

THERAPIST: When was the last time she was hospitalized?

CLIENT: (pause) The second week of November.

THERAPIST: Oh wow, I didn't realize it was that recent.

CLIENT: Yeah.

[00:32:34]

THERAPIST: You came here when she was hospitalized, is that correct?

CLIENT: We came here just after she was hospitalized.

THERAPIST: I see. So this is the third time since like August or something. (pause) Oh, no, no, no. I mean, you came here meaning you came to Denver. Sorry.

CLIENT: I came to Denver. She wasn't hospitalized that time, no.

THERAPIST: Okay.

CLIENT: Yeah, we started seeing you just after her most recent hospitalization. The last time she was hospitalized before November was (pause) I think a year before that.

THERAPIST: Mmmm-hmmm.

CLIENT: (pause) Yeah, that's right. It was about a year before that. (pause) And then the time before that had been six months before that.

THERAPIST: Mmmm-hmmm.

CLIENT: Yeah.

[00:33:26]

THERAPIST: One thought I had I definitely need to think more about it, and I'm not even sure if you're interested and I have a few caveats to it. My concern now is I don't know, my thought now is, I mean couples' therapy sort of in a traditional sense is not something that is going to happen, I really think, for a while. I mean, in terms of let the two of you talk and work on your relationship I mean, it's almost kind of that piece of it. While I think it's extremely helpful for couples to talk, whatever is going on with them, you know, when someone is just in such distress and so ill in a particular way, it's kind of ludicrous on some level.

CLIENT: (laughter)

THERAPIST: I mean, quite honestly, again, in a traditional sense, I think that two people who are married talking about whatever is going on in their life is useful, though Tanya is not right here to talk.

CLIENT: Sure.

THERAPIST: One thought I had, and we really need to think about this very much and you may not even be interested in it, is if you wanted to work with me, if you felt that this was a good alliance and you wanted to work with me, and then at some point if you guys did want to re-engage in couples' therapy, you would go to somebody else, if you feel like this is a good relationship.

[00:34:30]

I'm just sort of trying to prioritize needs. Now, of course, it would be (a) that you'd want to and (b) that Tanya would be okay with that.

CLIENT: Right. (pause) I like you and I like working with you, and I feel like you know what's going on in my life already, so that's useful. I really need to think about it, and I really need to talk with Tanya about it.

THERAPIST: Mmmm-hmmm.

CLIENT: I actually need to think about it before I suggest it to Tanya or talk about it with Tanya. Because I need to think about whether even the suggestion would be a bad thing for her, if that makes sense.

THERAPIST: How do you know?

CLIENT: Just in the sense that when she was in the hospital the last time, the inpatient psychiatrist suggested that the therapy that she was doing with Chad was not indicated for someone with her symptoms, that it was probably making things worse, which if there was anything that made things worse, it was him saying that. (chuckles)

[00:35:32]

Because she's got this relationship with Chad that she's developed over a long period of time and she feels like it's her lifeline, and this guy is attempting to take it away in some sense. So that was really bad.

THERAPIST: Oh. So she might feel the same way.

CLIENT: She might. You're not a lifeline for her in the same way that Chad is, you know. You have been treating our relationship and you've been very clear about that, so I don't think it has the same potential problem. But I want to think hard about it before I risk that, if that makes sense.

THERAPIST: Actually, you know, I want to put that out there as an option to think about. It's not like I heavily think that that's the way it should go.

CLIENT: Okay.

THERAPIST: I'm just very much wanting to sort of like I said, sort of prioritize needs right now and just think like that, but there might be more downsides. I don't know. I have to think about it more myself.

CLIENT: Okay.

THERAPIST: I just wanted to put it out there.

[00:36:30]

CLIENT: I appreciate you suggesting it and offering it. I will think about it and you will think about it and I'll talk with Tanya.

THERAPIST: Yeah, yeah.

CLIENT: I guess we'll see what we all come up with.

THERAPIST: Yeah.

CLIENT: That seem okay?

THERAPIST: That's fine, you know, yeah, that's fine. If Tanya doesn't feel comfortable with it, I don't since my contract is with the two of you, I wouldn't feel right about that.

CLIENT: Absolutely, absolutely. Nor would I, so I think we're on the same page there.

THERAPIST: I know. It's just, you know, I'm sort of trying to think through. So much is kind of unknown and up in the air and there's immediate circumstances that need to be attended to, and so I'm trying to be sort of thoughtful about it and just think about all the different options.

CLIENT: Yeah, thank you. (pause)

THERAPIST: But it does sound very scary. (pause)

[00:37:26]

CLIENT: It is, yeah. (pause) I'm actually pretty hopeful about the ECT. I don't know what we'll do if it doesn't work. (pause) Hopefully a medical professional will have an answer in that case.

THERAPIST: Yeah, I mean, ECT is supposed to be some of these sort of older methods of treatment, they're there for a reason and they stay around for a reason. What was the thought about because she hasn't had this before, right?

CLIENT: That's right.

THERAPIST: So what was the thought, like how did the decision come to be?

CLIENT: Well, so she's at Frederick. I think they do a lot of ECT there because I think it works. I think they also see a lot of patients who have tried a whole lot of medications. So Tanya is up to, I don't know, 15 or something medications that she's tried that haven't really worked.

THERAPIST: Wow. That's a lot of medication.

CLIENT: Right. And so she, in talking with her psychiatrist, her psychiatrist seemed not to think her outpatient psychiatrist seemed not to think that there was a clear next medication to try that would really work.

[00:38:39]

So she was kind of thinking let's try shifting nutrition, and let's try sticking with the medications that work a little bit and see what we can do to make them work a little bit better, but seems to have given up on finding the silver bullet. And so in that context then, ECT is kind of a next step when things get worse again, I think. It's certainly something that has been mentioned before. And so the inpatient psychiatrist suggested doing it. I think Tanya's thinking was we have to try something because she can't take where she is, and there doesn't seem to be a medication that's an obvious next step. If you're going to start doing ECT, you may as well do it at the place that's supposed to be the best.

THERAPIST: Mmmm-hmmm.

[00:39:34]

CLIENT: Plus, if she were to wait wait until there was another crisis and then start, who knows which hospital she'd end up at.

THERAPIST: Frederick is a very good hospital overall.

CLIENT: That's what everyone seems to agree, yeah.

THERAPIST: Does it feel that way to you?

CLIENT: Yeah, it does, it does, yeah. She's had, you know, a run-in with one of the nurses who (chuckles) started off entirely on the wrong foot by persisting in calling her Miss Tanya, which I don't think Tanya liked very much when she was 10 and really doesn't like now.

THERAPIST: It's a little patronizing.

CLIENT: Yeah, yeah. But other than that one nurse, like everyone else has been really good and she likes her inpatient psychiatrist, which is a first.

THERAPIST: Well, that's good.

[00:40:25]

CLIENT: (chuckles) Yeah. So yeah, and they seem to do things well. I don't have any real complaints other than that nurse. There's always someone. I think it's very hard to be able to treat every patient who comes through perfectly.

THERAPIST: Have her parents or your parents been here yet?

CLIENT: No.

THERAPIST: Who is first in the queue?

CLIENT: Her sister. (pause) Last time she was hospitalized, she didn't really want to see anyone, it seemed like. She just didn't.

THERAPIST: So this is the first time she'll have people visiting her from out of town?

CLIENT: This year.

THERAPIST: [This year].

CLIENT: At the previous at the hospitalization in the fall, her father came up to visit. Of course I was out of town then, so I came in to visit also.

[00:41:30]

THERAPIST: Do those visits from her parents make things better, the same, worse?

CLIENT: At the time, it seemed to really help that her father was there. In the last year or eight months in talking with Chad, she's kind of uncovered some more resentment about her upbringing. So I think it's not quite as clear that her father visiting would be as helpful because she still hasn't quite resolved what she needs to resolve with him and what she just needs to come to terms with herself.

THERAPIST: God, it's such a complicated situation and it is, you know, there's no right treatment. I respect Chad's clinical judgment and his work so deeply, I really do. It's very hard. I mean, people have very different opinions on the kind of treatment people who are at this level of distress should get. There's no right answer.

CLIENT: What sort of tracks do people go on?

THERAPIST: Right. There's no right track.

CLIENT: Sure.

[00:42:29]

THERAPIST: Certainly the track that Chad is taking in terms of really trying to get underneath the distress with the hopes of alleviating it over time is one track that people go on, and it's more intensive treatment. Another track actually when I had spoken to him briefly, he had thought that this could be a good additive at one point. People do either cognitive behavioral therapy or what's called DBT. I think it stands for Dialectical Behavioral Therapy where there's a little bit more focus on managing symptoms, like a much more kind of skills-based very specific management of the distress and what to do with it in the moment, rather than necessarily the underlying causes.

CLIENT: Right.

THERAPIST: And that's definitely another path that people take. They're not mutually-exclusive. I remember when I talked to Chad he'd said, you know, maybe that could be a good additive.

CLIENT: Right.

THERAPIST: But there's a lot of theories that, you know, someone at this level of pain, uncovering things just makes things worse which is probably where the psychiatrist was coming from.

[00:43:32]

And other people feel like, you know, what's the alternative? Like just covering it up and, you know, putting some masking tape over it, sending them on their way. I don't feel like there's a right answer. There's just a lot of different opinions, all with a lot of merit, I think.

CLIENT: Okay.

THERAPIST: Or at least some of them with merit and some of them not so much so.

CLIENT: (chuckles) Okay.

THERAPIST: Have you had concerns?

CLIENT: About Chad's treatment?

THERAPIST: Chad or any of it, yeah.

CLIENT: My only concern is that the suicidality has increased over time. I would really like to see them work a little bit harder on managing that so that because I really think that Chad's approach has been useful and successful for her in a general sense, except obviously we're back in the hospital so it hasn't been it hasn't cured her, but I think it is working.

[00:44:32]

I think it is (pause) I think it is a useful way to go, whether it's the only one or not, I don't really know. But it's definitely been working for her, I think. So just a little bit more management of the worst parts of it so there wasn't this constant threat that it's going to end, I think would really be helpful. I also trust Chad a lot and I've talked with him briefly in each of the last two crisis times. I really think he has a good handle on where she is and is very perceptive and acute.

THERAPIST: We really need to stop -

CLIENT: Okay.

THERAPIST: and I'm wondering, what would you like to do from here?

CLIENT: I'm not sure. Can we be in touch by e-mail? Is that okay with you?

[00:45:28]

THERAPIST: Absolutely, absolutely. You know, I laid out a couple of options. I certainly also if you guys want to continue using me as a couples' therapist, I really don't see you know, unless Tanya has an objection I don't see us meeting, you and I meeting, until she gets out of the hospital necessarily a problem, as long as we talk about it and think about it.

CLIENT: Okay.

THERAPIST: That's sort of what I'm thinking.

CLIENT: Okay.

THERAPIST: I certainly don't especially in these situations don't like drawing lines in the sand. You know what I'm saying? So I like to be flexible but thoughtful about the decision. So you know, in presenting the possibility of us working together going forward, I don't feel like that decision needs to be made right now and to just sort of leave things, like I said, flexible but thoughtful.

CLIENT: Okay.

THERAPIST: Does that sound like a plan?

CLIENT: It does, yeah.

THERAPIST: Okay.

CLIENT: Yeah. (pause) Yeah. So in a sense, we just need to figure out what we're going to end up doing, or I need to talk with Tanya and see what she is comfortable with in terms of I think she is comfortable with us continuing to meet in the theoretical pursuit of couples' therapy. She certainly was today.

[00:46:43]

THERAPIST: Would it be helpful if I met you know, I'm in communication with you and I'm not in communication with her do you think it would be helpful for me to be in communication with her right now? It just seems like she has her own immediate issue to deal with.

CLIENT: Yeah.

THERAPIST: I don't know. I feel like this is a layer that may not be as urgent right now.

CLIENT: If you want to be in communication with her, she does have e-mail access. I don't think it would hurt -

THERAPIST: Yeah, maybe I will.

CLIENT: for you to be in communication with her.

THERAPIST: I wasn't sure how I didn't realize she has been in the hospital for this amount of time. I thought she just got there like two days ago.

CLIENT: Yeah, I'm sorry.

THERAPIST: No, no, no, that's okay. So I think that part of it was I wasn't going to contact her if she just got there.

CLIENT: Right.

THERAPIST: It makes less sense. But actually I think I will reach out to her.

CLIENT: Okay.

THERAPIST: It sounds like you let her know we met -

CLIENT: Oh yeah, no, no.

THERAPIST: And you know, sort of encourage the two of you to talk about things more and for us all to be in contact.

[00:47:34]

CLIENT: I think that sounds good.

THERAPIST: Okay, great.

CLIENT: Thank you very much.

THERAPIST: Absolutely, absolutely. I look forward to hearing from you.

CLIENT: Okay, thank you.

THERAPIST: Bye.

CLIENT: Bye.

END TRANSCRIPT