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1005577352 130116_002

THERAPIST: Hi good morning. I'm just going to grab some water. (pause at 00:00:07 until 00:00:22)

CLIENT: Good morning.

THERAPIST: Morning. So how are you?

CLIENT: I'm okay. So Tanya is coming home today at least in theory.

THERAPIST: Mm-hmm.

CLIENT: I haven't heard from them exactly when she's coming out. So. I think that's a good thing. She's definitely tired of being there. And so staying there may or may not help for much longer. The sucidality seems to be going. At least for now. So that's good. I'm sure she's she's talking with Chad about not starting the job search again immediately. Which is good. I support that because my real concern was that she was going to come out and attempt to jump right back into everything that had put her into the hospital in the first place. So. [00:01:15]

THERAPIST: Mm-hmm.

CLIENT: That looks like it's not going to happen. So. That's reassuring. She's going to continue doing the E.C.T. and they're saying easy path if she's not doing well for the E.C.T. admission people to admit her back into the unit she's in currently. So that's good. It's kind of like there is a safety net for this. Which I think is an important thing.

THERAPIST: Mm-hmm.

CLIENT: The other thing is like if she comes out and suddenly gets worse again, then we go back to the emergency room. That's a nightmare really. And then we go somewhere else. There is no guarantee we'd end up back in Frederick. And there is no guarantee we'd end up anywhere that was very helpful. I guess we've been to four different hospitals now. And I feel like two of them would be less helpful to return to than the other two. [00:02:06]

THERAPIST: Is that where you went two weeks ago? You went to the E.R. first? Is that-?

CLIENT: Yeah. We don't know any better admissions route when she's in the wants to kill herself crisis. (inaudible at 00:02:22) somewhere to stabilize. And then they never have a bed in whatever hospital you go to. So they always do a bed search and send you wherever they have a bed.

THERAPIST: Mm-hmm.

CLIENT: So. We got lucky this time that it was Frederick that had a bed.

THERAPIST: Mm-hmm.

CLIENT: So that's that. I'm a little nervous because I think Tanya is upset with me because she told me on Monday that she wanted to get out. And on Sunday she hadn't been particularly well. Much better than the previous Sunday but not in sort of the normal range of (pause at 00:02:59 until 00:03:06). (inaudible) And normal is a really -

THERAPIST: Subjective? [00:03:09]

CLIENT: Yeah. Yeah. If you picked the average person off the street the normal range of their moods, I'm not sure she was in the bottom end of that in the worst part of Sunday. So it's a little concerning to have her say the next day, "No I should definitely be coming home on Wednesday."

THERAPIST: Mm-hmm.

CLIENT: Well I'm a little concerned that you're going to come back and want to kill yourself because you're going to want to do all of the work again. (pause at 00:03:33 until 00:03:40) That conversation didn't go very well. She didn't want to hear that. And (pause at 00:03:44 until 00:03:50). I don't know exactly why that was. There are two components I think that I'm pretty sure are going on. One is the E.C.T. is making it hard for her to remember things.

And so it's making it hard for her to have long conversations because she can't remember with perfect clarity everything that went on in the beginning of the conversation. And the other is she has I think some abandonment anxiety and so me saying, "I'm not sure that's a good idea" I think triggered some idea of like I was just going to leave her in the hospital or something. But I'm not sure. [00:04:30]

THERAPIST: Mm-hmm. So did you guys get into a fight over it or-?

CLIENT: I think she would describe it as a fight. I didn't think we were fighting but she seemed pretty convinced while it was happening that we were fighting. But I didn't have anything to fight over so I'm not really sure what was I was mostly confused as to what was happening I guess I would say. I feel like there are these concerns that need to be addressed. And then she seemed to have enough anxiety that she almost couldn't respond. And then I would ask her what was going on and she would just kind of not have an answer. (pause at 00:05:13 until 00:05:21) I didn't feel like it was a fight but she did. So I guess that counts? I don't know.

THERAPIST: Mm-hmm.

CLIENT: So. [00:05:27]

THERAPIST: What has it been like for you having her go through E.C.T.?

CLIENT: Well she's just had her well today she will have had her fifth session and it changes a little bit every time. So she responded really badly to the medications they administer with it the first time. And just was really weepy and depressed and had a very bad headache the first day. So they started giving her ibuprofen so the headache wasn't there the second time and she was less sad. I think the second time was the time she woke up and couldn't remember who she was as first. So I think that was a little hard for her to deal with. I have avoided imagining what that's like because I feel like one of us experiencing that is enough at any given moment but I can say that was pretty bad for her. [00:06:25]

The third time it was better on both of those two fronts but she then started to it became more clear the next day or two that she was kind of forgetting pieces of conversations. But she would remember all of the conversation and then not the start of the conversation that happened right after it. And then she would remember all of the next conversation. So it was just like it seemed entirely random as to what she remembered and didn't remember. So it's kind of interesting at that point. It also seemed like it was working a little bit in terms of her moods seemed better. She seemed cheerful.

After the fourth treatment on Monday she seemed to this is when we had the maybe fight she seemed to have a much harder time remembering a whole range of things. It was still random but it was just more frequent for recent things. (pause at 00:07:24 until 00:07:31) And then she seems to get stuck in trying to remember whatever specific thing she really wants to remember at that moment. So it gets hard to have a conversation of much length. So that's been an evolving thing and a little bit strange in each step. [00:07:47]

THERAPIST: Mm. Well that sounds like that's what it's been like for her mostly. And I can't imagine this is anything short of terrifying for you. At least at times.

CLIENT: The whole situation is terrifying. I'm not particularly worried about the E.C.T. at this point. (pause at 00:08:13 until 00:08:22) From the bit of reading that I did I'm pretty confident that the if the memory effects are going to be short term so she may never remember very well these few weeks. But that seems like a small price to pay. If it works. If it doesn't work I'm not sure that some of the other medications haven't done things that are just as bad. So I'm not particularly scared of that. [00:08:47]

I am in a general sense terrified that she's still we still don't have a really good treatment plan. And that she'll kill herself. (pause at 00:08:59 until 00:09:09) Well. (pause at 00:09:09 until 00:09:21) I'm less worried about that today than I was Sunday or Monday. I was less worried Monday than I was Sunday but (pause at 00:09:29 until 00:09:37). This particularly bad Sunday I felt like she'd regressed several days and was back to a pretty unhopeful place pretty quickly. That's not what I like to see in the sort of trends of the treatment. But still very early in the E.C.T. Or it was then. The normal course seems to be eight to twelve doses. [00:10:06] (pause until 00:10:21)

THERAPIST: And you've been continuing to talk to people?

CLIENT: Yeah.

THERAPIST: Mm-hmm.

CLIENT: (inaudible at 00:10:26) Yeah I've continued to talk to my parents and to Tanya's father. Sometimes with her sister who arrived last night. Sometimes I've just been e-mailing back and forth with her sister but either way it's somewhat helpful.

THERAPIST: Mm-hmm.

CLIENT: And I have a good friend who is here. Also lives in Andover. He's been going out to visit Tanya with me because they're also good friends. About half the time. So that's been good. [00:10:54]

THERAPIST: Mm-hmm.

CLIENT: See I've been talking to people. That's helpful. (pause at 00:11:02 until 00:11:21) Yeah it's helpful. At some point everyone is in a sense just scared and helpless. And so there is some amount of that that is reassuring and there is some amount of talking about it that's reassuring. There is some extent to which it doesn't address the root problem for anybody. But that's the situation we're in.

THERAPIST: Mm-hmm. (pause at 00:11:42 until 00:12:05)

CLIENT: The loneliness seems to go along with the fear. So the more scared I am that Tanya is going to die, the more lonely I feel also. [00:12:13]

THERAPIST: (inaudible)

CLIENT: I don't know if those are directly related in that way or if they both just stem from her being really unwell. And so in a sense not present.

THERAPIST: Mm.

CLIENT: I'm not sure. (pause at 00:12:25 until 00:12:34) I would say that the talking with people has helped less this weekend with the loneliness. Just there's it's just hard to have Tanya be getting dramatically better really and then really not be as well. Or not seem as well. Of course by Monday she'd had E.C.T. and didn't really remember not feeling well on Sunday. So I'm not quite sure whether that's a good thing or a bad thing. So. [00:13:06]

THERAPIST: You remembered.

CLIENT: Yeah. Yeah I did. It's a little strange to have the conversation where "Well you really weren't that well yesterday." And she's "I wasn't?" "No." Don't really remember. So. (inaudible at 00:13:23) good. You may as well not remember that. (chuckles) If you forget anything, let's forget that. But it's still yeah I guess I have to deal with that alone then too.

THERAPIST: Mm. (pause at 00:13:37 until 00:13:45) Well it's like this is a comparison that makes sense in some sense. Like a spouse who has Alzheimer's. Obviously the memory problem is pretty short lived and so forth but just feeling like your realities are very different. And feeling like that person is out of touch and hard to make contact with. [00:14:04]

CLIENT: Yeah. Yeah I fortunately it's not nearly a perfect analogy. But Alzheimer's seems pretty terrible.

THERAPIST: (inaudible at 00:14:15)

CLIENT: No.

THERAPIST: I didn't mean to scare you with that analogy. I was trying to just search for something.

CLIENT: No you no. That had occurred to me also.

THERAPIST: That particular one?

CLIENT: Yeah. Yeah.

THERAPIST: Mm.

CLIENT: And that may be because my friend who is a poet and his wife is a neuroscientist she studies Alzheimer's. So it's kind of it's a disease that it's in the forefront of my knowledge in some way.

THERAPIST: Mm-hmm.

CLIENT: So. I've talked with them about the E.C.T. so it's kind of like it falls in her court in some way because it's a memory issue. And so it occurred to me. [00:15:01]

THERAPIST: Mm-hmm.

CLIENT: It's not the same and I'm glad of that. But it does have a lot of similar elements. Yeah. The realities we live in are somewhat different. And I have this sense of her not living in the reality that actually is real in some way. There is a world going on. And just because she doesn't remember an element of it doesn't mean that it wasn't there. (pause at 00:15:23 until 00:15:30)

THERAPIST: But I guess I mean maybe the analogy can stretch even further. Because if we don't think about the memory issue per se there is this feeling that you don't know what is going on for her. And in a much more systemic way is kind of just something that is a different kind of reality. I mean being in the mindset of wanting to end your life is a particular kind of reality that certainly you're not in. [00:15:57]

CLIENT: No.

THERAPIST: And it's hard for you to relate to.

CLIENT: That's right. Yeah it's not one I've ever been in.

THERAPIST: Mm-hmm.

CLIENT: For which I'm glad. But really don't know exactly where she is when she goes that way. Yeah that's right. (pause at 00:16:15 until 00:16:39) Yeah that's particularly hard because then I have no idea what to do or say. It's very clear to me that there's not good things to do and say but it's not exactly clear what they are until I have already said them.

THERAPIST: Mm.

CLIENT: And then they don't always work the same way the next time around. [00:16:56]

THERAPIST: Mm-hmm. It's kind of like shock treatment? I mean not E.C.T. but shock treatment. You do something and then you get a negative like you get shocked or something.

CLIENT: Right.

THERAPIST: There is some negative consequence. That's what I mean. (inaudible at 00:17:09)

CLIENT: Yeah, no. That's exactly right.

THERAPIST: That's not a great way to learn.

CLIENT: (laughing)

THERAPIST: It's certainly not a fun way to learn.

CLIENT: Yeah. I think you learn not to do things that shock you but if I think. If I understand it correctly one of the problems with abuse is in general not having a really clear sense of when the shock is coming.

THERAPIST: Mm-hmm.

CLIENT: So it falls into a category more like that. There is a shock but I don't always know when it's going to happen.

THERAPIST: Learning can't take place in that context if there is no correlation.

CLIENT: Right. Right. Yeah and maybe the system is non-linear and that's why there is no obvious linear correlation. But non-linear systems are really hard to (inaudible at 00:17:54) out of. So we still don't have a good internal sense of how to do that. Yeah. (pause at 00:18:06 until 00:18:56) And then it's hard making any sort of decision with her at this point.

Now the E.C.T. booklet that we have recommends that you not make any important life decisions while doing E.C.T. because you may not be able to remember all of the important factors which makes sense. But somewhere in here we're attempting to decide what role you play. Our therapists. I mean I can't really have enough of a conversation with her to be sure of what she really wants or needs. [00:19:27]

THERAPIST: Mm-hmm.

CLIENT: And I'm not really comfortable making a decision of that magnitude for both of us without some reliable input from her.

THERAPIST: Mm-hmm.

CLIENT: I'm not sure she's going to remember from day to day what she said the previous day about any specific topic. This one included. So I don't want to make a decision with her and then act on it. And then say "Oh no, no. You totally agreed to that." Because that seems like then she's alien to herself also or something.

THERAPIST: Mm-hmm.

CLIENT: So.

THERAPIST: When it comes to that decision I mean I think I agree. We'll figure it out.

CLIENT: Okay.

THERAPIST: No need to make something today.

CLIENT: Okay. I appreciate that.

THERAPIST: You know it would be fine. The three of us can meet when it sounds like next week she'll be out and we can talk about it then. That seems like yeah we can figure that out.

CLIENT: Okay.

THERAPIST: It doesn't seem like from my vantage point why this needs to happen right away.

CLIENT: Okay.

THERAPIST: Unless you really feel like you really need your space soon. Outside of her. And then maybe that's something to think about. [00:20:31]

CLIENT: Yeah. (pause at 00:20:31 until 00:20:38) I don't have any issues that are separate from what she's dealing with right now. Or not any of any real significance. So I guess I don't need my own space in that regard. I have a general sense right now that while she's in this memory state, couples' counseling is not going to be enormously effective because it tends to be a long session. And she can't remember for a five minute conversation what was going on at the beginning or keep it all bundled up in some way that I don't know that we're going to make a whole lot of progress of any kind. (pause at 00:21:20 until 00:21:33)

THERAPIST: Will she be going to her sessions with Chad?

CLIENT: She's been calling him a couple of times a week. I mean it's not the same over the phone. And so if she does get out today hopefully she'll be able to go to her Friday session with Chad. [00:21:48]

THERAPIST: Mm-hmm.

CLIENT: So that would be good. (inaudible at 00:21:53) group counseling in the hospital but that's also a different thing.

THERAPIST: Does she find that helpful?

CLIENT: I think it depends on the make up of the group and who's running it. Some of them I think she finds helpful. Some of them I think she really doesn't like.

THERAPIST: Mm-hmm. Well now I want to talk more about other decisions maybe that you have on your mind because you said decisions in general. But you'll have my support in some form whether I'm meeting with the two of you, whether I'm meeting with you alone. As I've said for probably since the beginning there is sort of an exigency to this situation that having sort of a rulebook makes really no sense. So to have some thoughtful fluidity is what my goal is right now. You know? So I don't -[00:22:48]

CLIENT: (whispered) Thanks.

THERAPIST: Nothing needs to be determined today or next week for that matter. So.

CLIENT: Okay. Great. Thank you. That's helpful.

THERAPIST: Mm-hmm.

CLIENT: That's helpful. I think you said the same thing last week but (chuckles) but it got hard to remember that as the week went on. So I felt more like we needed to have some sort of decision.

THERAPIST: Yeah. Yeah. And I had sort of like in retrospect and sort of e-mailing Tanya I don't know. That could of waited. I like to have her feel included but there's yeah.

CLIENT: (laughs) I think it was a good thing.

THERAPIST: Okay.

CLIENT: It certainly didn't hurt in any way.

THERAPIST: Mm-hmm.

CLIENT: So I think that was good. It gave her a chance to directly weigh in to you so that I'm not relaying messages one way. So I think that was good. There is this sense in which I'm not really sure whether what we need right now is a couples' therapist. Or whether each of us just needs our own like therapy of some kind. [00:23:47]

THERAPIST: So my thought about that is I agree with that mostly.

CLIENT: Okay.

THERAPIST: In terms of like couples' therapy in quotes, traditional where people work on issues to better the relationship, I mean that's ridiculous at this moment.

CLIENT: (laughs)

THERAPIST: I mean it's really ridiculous.

CLIENT: (laughing) Okay.

THERAPIST: In the sense again really in a very sort of narrow sense. Traditional sense. Tanya is very ill right now and she needs to get better. And so even in the context of you're feeling like you want to be infuriated with her if you want to be and feeling like what's the impact on her I mean for you to be concerned about that or that wasn't a really good example. Yeah. So traditionally conceived couples' therapy doesn't make a whole lot of sense right now.

That's not to say that I can't be a support for the two of you in meeting with you and just thinking about the meaning of her illness. Practical considerations for the week. I mean I think there is a lot of good that can be done. I do feel and I think I said this in the e-mail that you being in your own treatment does seem like a priority in my mind but they're not mutually exclusive. [00:24:59]

CLIENT: Okay.

THERAPIST: You know with me I think they would be but getting both those needs met are not mutually exclusive.

CLIENT: (chuckles) Right. Okay. (pause at 00:25:10 until 00:25:19) Yeah and so I'm not sure what we need to do. It's (pause at 00:25:24 until 00:25:53). Yeah it's sort of like I don't really know what Tanya needs. I think there is an element in which we started coming here because Tanya wanted me to being seeing someone. That was not the whole reason we started coming but I think that was in her mind also. And so yeah I just really don't know what we need at this point. And I don't have a very clear vision of what individual therapy looks like because this is the closest to that that I have ever done. So -

THERAPIST: It would look like this. [00:26:29]

CLIENT: It would?

THERAPIST: It could look like this. Sure.

CLIENT: Okay. All right. Okay.

THERAPIST: Did you have other thoughts about that?

CLIENT: Well just in the sense of there are uncertainties in a lot of different pieces of the decision. And it's hard to decide in the face of uncertainty. Just try to take (inaudible at 00:26:49) outcome but it's not a good way to pick it.

THERAPIST: Mm-hmm.

CLIENT: If you don't really know enough things. In this case I don't really know what Tanya needs or wants from the situation. So I can kind of talk with her and then I have to assess how reliable what she said is as an indicator of what she needs and wants. (pause at 00:27:07 until 00:27:22)

THERAPIST: Well I think it's also sort of what were you just thinking?

CLIENT: I was thinking well the experimentalist in me wants to just ask her a few more times and see if the response is more or less consistent. If we kind of converge on a consistent response that's probably a decent indicator of what she at least thinks she needs. She may not remember it so it would be okay. That's kind of what were you going to say? [00:27:51]

THERAPIST: On a really practical level yeah. I mean on a really practical level you guys can get both. In terms of meeting someone together and you meeting with someone individually.

CLIENT: Absolutely.

THERAPIST: So on a really practical level that can and will happen.

CLIENT: Sure. Sure. But also on a practical level she also needs to be doing E.C.T. three times a week. At least for the next week or two or however long. And that means going (inaudible at 00:28:21). An hour for the treatment. A couple hours for recovery. Come back and then someone has to stay with her for the rest of the day.

THERAPIST: Mm-hmm.

CLIENT: Just as part of the treatment. I think there is a risk of seizure or something.

THERAPIST: Are you the only one doing that right now?

CLIENT: Um, well while her sister is in town, which will be through Sunday, no. After that we don't have a plan. It sounds to me like you're hesitant to have me be the only one doing that. [00:28:52]

THERAPIST: Yes.

CLIENT: And I am hesitant to be the only one doing that particularly in light of your previous recommendations on similar subjects.

THERAPIST: Yes. Yeah.

CLIENT: So my friend Neal, if he's in town, I think would be willing to do at least some of that.

THERAPIST: Mm-hmm.

CLIENT: At least some of the time. And there are Tanya's kind of become a part of a church community in downtown Denver over the last year. And I feel like there is a way to get some support in that process from them.

THERAPIST: Mm. Mm-hmm.

CLIENT: So. And I don't have an answer as to how we're going handle it but it is on my mind not to just do it myself.

THERAPIST: Mm-hmm.

CLIENT: But that's three days a week there. Then the other two days presumably Tanya is going to want to do individual therapy with Chad. Because she's probably not going to be able to do it at least some of those three days.

THERAPIST: Mm-hmm.

CLIENT: She's been meeting with Chad four times a week. So now on a practical level where do we fit in couples' therapy while she's doing that? In addition to it I just don't think it's a good idea. [00:29:54]

THERAPIST: Right.

CLIENT: But we need to do it. So there is kind of like the practical concerns. Like it doesn't seem useful. And I don't know when it becomes useful again because I don't know when she's going to stop doing E.C.T. Or when her kind of short-term memory inability to function is going to recover fully.

THERAPIST: Well look if it's helpful for you to be here which it seems like it is keep coming and when Tanya is able to come again we can have the discussion in terms of what you guys what to do going ahead.

CLIENT: Okay. Thanks.

THERAPIST: Yeah.

CLIENT: If that's not a problem for you then -

THERAPIST: Like no. This is I want to be adaptable to the needs of the circumstance. The situation we'll sort of figure it out. Maybe things will become more clear just in terms of us doing going ahead with the (inaudible at 00:30:41) about it.

CLIENT: Okay. Thanks.

THERAPIST: Yeah. (pause at 00:30:43 until 00:30:51)

CLIENT: That seems like an appropriate way forward to me. [00:30:52]

THERAPIST: Mm-hmm. (pause at 00:30:53 until 00:30:59) Are there other decisions you feel that need to be made?

CLIENT: Nothing that feels like it has that same magnitude. It's kind of whenever she's in the hospital there is this question of who should come visit her. Does she want Franco to come with me on any specific day? Does she want her father to come up? So I sort of have to make those decisions. At this point. (pause at 00:31:20 until 00:31:31) There is a sense in which she didn't want to make those decisions while depressed. She didn't want to face any sort of decision.

And then started the E.C.T. and is maybe not a place to make major decisions. So it's kind of been a continuous process while she's been in the hospital of not really being wholly in control of her decision making process or something. Not that I would say it in those words to her. (pause at 00:31:58 until 00:32:05) Which is tough because I've worked very hard particularly during our married time to make decisions that affect both of us together. Actually I don't think unilateral decisions are in general a successful strategy. Certainly they need to be made sometimes but if we can work together to make a decision it seems like we ought to. [00:32:32]

THERAPIST: Mm-hmm.

CLIENT: So we have done that. So now we're in a place where we can't anymore but the thing that I'm used to doing is to talk through the decision and kind of look at the options together. And then pick one together. So I guess I don't have any other good examples off hand. But mostly it's been visitation things. And then this therapy thing. I guess the question of when she leaves and what she's going to do once she's left. You know that's been very important to me for her not to get out and go right back into the same situation that seems like it precipitated the problem. She agreed with me last week and then kind of over the weekend seems to have forgotten that was an obvious concern or something. And so by Monday really wants to get out of it. [00:33:36]

For me the circumstances external are still the same. She hasn't done anything to get back to doing work inside. And it's not clear to me that she won't want to start applying for jobs as soon as she gets out. Now that was the situation Monday. Today I don't feel like that's the same thing. Because I've raised those concerns and she talked with Chad the next morning. And he said, "Well I don't think you should go back to doing a job search at all when you get out. Like you should just wait for awhile and see if the E.C.T. works. Because we'll know in a couple of weeks. And I don't think you need to be looking for a job during that." Which is fine. I am very okay with that. I just didn't think she would be capable of doing that. [00:34:21]

But I feel like with that recommendation from him and some insistence from me she'll be able to do that. That's why I'm okay with it but (pause at 00:34:35 until 00:34:46). I feel like I've talked into a bit of muddle. But the decision is sort of what are we doing with her treatment? And what are we doing with easing her back into normal life? One strategy was to have her stay in for longer. And then ease back into it while in a safe place. One strategy is for her to come back out and ease into it under therapeutic guidance of her outpatient treatment team. [00:35:17] (pause until 00:35:25)

There is not any good reason to prefer one over the other. Or not any there are reasons to prefer each. The only reason I had been leaning towards the residential one is that I wasn't sure we had the margin of error necessary to do the outpatient one.

THERAPIST: Mm-hmm.

CLIENT: I think we might at this point. And particularly if she is actually willing to ease into things. And it seems like Chad is going to continue to push her in that direction. Then I think it will be okay.

THERAPIST: Mm-hmm.

CLIENT: But again it's a conversation in her mind it was almost a fight from the start. And in my mind was I don't know what. I would try to say things like what I've just talked about. She would (pause at 00:36:19 until 00:36:26) seemingly not be able to grasp what I was saying.

THERAPIST: Mm-hmm.

CLIENT: Which is really not usually the case in talking to Tanya. So. It's kind of a big decision though. How are we moving forward in this treatment? To not be able to discuss it and have some agreed plan is not easy. [00:36:48]

THERAPIST: Mm-hmm. (pause at 00:36:49 until 00:36:56) So then you end up feeling like you need to make the decisions for her treatment alone.

CLIENT: Yeah ultimately if she can't. And if her treatment team isn't making them with all of the considerations that seem correct to me not that I trust Chad. I think he's got a very good handle on where Tanya is. I'm not always as sure about inpatient treatment teams because their focus tends to be very much on stabilization in the moment. That's a good thing. An important thing. But stabilization is really useless if you get someone stable and then send them right back to where they were because the instability was caused by something. So if the cause isn't gone then you've done nothing other than keep them alive and delay. [00:37:47]

THERAPIST: Mm-hmm.

CLIENT: So I think they're more aware of that than it looks like they are because they very rarely talk with me directly. They do it maybe on intake and maybe on release. I guess always on release. And so I only get things filtered through Tanya as information for what they're doing. But they're not telling her everything that they're thinking and then she's not so. Perhaps my distrust of the inpatient treatment teams is unwarranted. But -

THERAPIST: I think they very much see things the way you described. I don't even know if they would call it a treatment team because it is a sort of getting out of the crisis and moving on. [00:38:36]

CLIENT: Okay.

THERAPIST: I don't even know if they would think of it as treatment per se. (inaudible at 00:38:40)

CLIENT: I see. Just stabilization.

THERAPIST: I do. I think that's what inpatient I mean with the E.C.T. component hopefully but I do think that most inpatient units that's what they see their role as.

CLIENT: Okay.

THERAPIST: I could be mistaken in that. But I don't know if that's comforting or not.

CLIENT: Um it's comforting in that I like it better when I can trust what I observe.

THERAPIST: Mm.

CLIENT: So it's comforting to have you say, "No that seems about right."

THERAPIST: Mm-hmm.

CLIENT: It's not really comforting in terms of taking care of Tanya. And it sort of plays into my feeling that I need to be monitoring very carefully how they decide to handle her situation because they are not considering all of the relevant factors all of the time.

THERAPIST: Yeah I mean I was trying to sort of think and then draw some analogies. I mean it's very difficult to have a spouse who is ill. And a spouse who can't collaborate with her treatment the illness impairs that to some extent. [00:39:40]

CLIENT: Yeah.

THERAPIST: Then when you as the spouse are integrally involved in a sense providing some of that treatment, providing "just being there" and make sure she's okay. You're not sort of on the side eliciting treatment but you're also sort of participating in it. Then the burden is all the more on you. Which I think why I've been particularly focused on having whatever we can build in place so that all the burden doesn't fall on you. I think I've been sort of attentive to that. Very much so. But one thing that sort of made me think what you said a few minutes ago about return to normal. I mean that's the biggest difficulty in this all what is normal going to be?

CLIENT: Yeah. Yeah I don't know.

THERAPIST: I don't think it's clear and I imagine that's extremely difficult. It's almost like farcical to think about planning in the context of not knowing what to expect. [00:40:39]

CLIENT: (chuckles) Yeah there is some of that. (pause at 00:40:43 until 00:40:49) Yeah I don't know what normal is. You look around what people do. Work some job and pay the bills and do whatever. People seem more or less happy. It'd be nice to get back to someplace like that but I believe that that's available. I don't know exactly what the path is to get there. I feel like that's not impossible to get back to a place where Tanya is doing something that she loves and finds fulfilling. And also pays her at least a little bit. I think that's possible. (pause at 00:41:32 until 00:41:39) So I guess that's sort of the end point goal that I would call normal. [00:41:44]

THERAPIST: Mm-hmm.

CLIENT: But we're so far outside of the range of normal anyway. Most people with any kind of depression seem to respond to some medication. So she's far out on the tail in terms of the number of medications she's gone through that don't work. But the E.C.T. is supposed to work for that category of people fairly effectively. Two thirds of people is a lot. And that's about the number for people who don't have psychotic episodes and fit into that category or fit into non-medicated category. But yeah I don't know what normal means.

THERAPIST: That's deeply unsettling. When you sort of function day to day with some concept of normal. I mean if everyday you wake up and who knows what will happen then in some very profound sense it's not very settling. And you have some sense that not everything is up in the air but I guess I'm just trying to sort of normalize the un-normalness of it. To provide a context for not having a context. [00:42:57]

CLIENT: (laughs) Yeah.

THERAPIST: If that makes any sense?

CLIENT: No it makes really good sense. One of the problems that I first had adjusting to Tanya's family is that no plan you make ever is going to be executed the way it's said. And in part someone is going to make the plan and they're going to tell it to other people differently. Because it's probably going to change between telling it to different people. So then everyone gets together and the plan never goes the way that anyone thought that it was going to.

For me my family just kind of makes a plan and then we do the plan. It's just how it always goes. It might change a little bit but not much. That was very unsettling for the first several years. Eventually I just realized that the plan is nothing is going to go according to plan. It's helped me get through the last three years just fine in interacting with her family. I don't make any plans and then expect them to be followed through in the same way that they were made. And somehow I'm very okay with that. So it seems like you're trying to do something similar with this circumstance. And say "Well it's really not clear what's going to happen. That's what's going to happen." [00:44:10]

THERAPIST: (inaudible) That's the clarity. Exactly. (laughter) (inaudible at 00:44:15)

CLIENT: Yeah that's helpful. The other thing I was thinking of is so most of chemistry is done in equilibrium things so all of our just about everything is done in equilibrium. But there are some reaction regimes that are just really far from equilibrium. So then most of the normal laws don't hold because you're just really far from the point where everything was derived and studied very carefully. And so we're kind of in that same situation.

THERAPIST: Mm. Mm-hmm.

CLIENT: So the important thing is again to recognize that we're not in this one place. And it's just we're elsewhere. It's really unclear. But it is clear that we are elsewhere.

THERAPIST: Mm-hmm. The most unpredictable something can be is trying to impose a predictable model that doesn't fit. Right? (chuckles) That's sort of what you're saying if you use [00:45:08]

CLIENT: Yeah I think that might be right.

THERAPIST: Yeah.

CLIENT: Yeah. So if you use a random model you'll get it right some percentage of the time depending on the distributions. And if you use the wrong model entirely you could get it wrong every time. Yeah I think that's right.

THERAPIST: Mm-hmm. We're going to need to stop in a moment.

CLIENT: Okay.

THERAPIST: How about I mean should the plan be that I'll see you next week and if you guys decide that Tanya is in a good place to come with you we'll do that. Like the appointment time is here.

CLIENT: Okay.

THERAPIST: And then whoever is coming, will come.

CLIENT: Okay.

THERAPIST: Does that sound like a plan?

CLIENT: It sounds like a good plan if that's okay with you.

THERAPIST: That is completely fine with me.

CLIENT: Great! Then I think that's what we'll do.

THERAPIST: And then we'll sort out the sort of what to do with treatment when that is sort out able.

CLIENT: Okay.

THERAPIST: Does that make sense?

CLIENT: That sounds perfect.

THERAPIST: Okay. So then I will see you next week.

CLIENT: Okay.

THERAPIST: Okay. Very good.

CLIENT: Thank you.

THERAPIST: Okay. Take care. Feel free to update me or whatever you need to share with me. Feel free to contact me.

CLIENT: Okay. Thanks a lot. Do you have other times if we have to do E.C.T. on Wednesday of next week?

THERAPIST: Let me e-mail. Yeah.

CLIENT: I'll e-mail you. So we should know maybe tomorrow or Friday what the E.C.T. schedule will look like.

THERAPIST: Okay. Okay. Great.

CLIENT: So I'll e-mail you if it looks like it's going to conflict. And we'll see about another time.

THERAPIST: Great. Great. Okay. So take care. [00:46:30] [End of audio]

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