TRANSCRIPT OF AUDIO FILE:

BEGIN TRANSCRIPT:

THERAPIST: Hi. Come on in.

CLIENT: So Tanya is going to come home today.

THERAPIST: Mm-hmm.

CLIENT: Which is what it is, she's not so-subtle (ph) anymore so-the insurance company says, "Well, obviously our work here is done." When I saw her yesterday she seemed-I don't know-better than I had seen her in a month or more, so I think that's good. So I think that's probably a testament to the ECT working, but it's not exactly clear. Yes, I got a call Wednesday afternoon from her case worker there, saying she was probably going to-getting home on Wednesday, right. Very, very angry. That conversation was fine, I didn't-wasn't angry until I hung up the phone. [00:01:10]

THERAPIST: This was (inaudible 00:01:15)-?

CLIENT: This was two days ago.

THERAPIST: I see, I see. Go ahead.

CLIENT: Very, very angry. It's kind of mid-afternoon; I was planning on visiting Tanya in the evening. Then I went for a walk, did the sort of things to manage my anger, that I usually do, like going for a walk, and trying to work through it. Thought I was-had my composure regained and then went to see Tanya in the evening and explained to her some of my concerns, just that we did this two weeks ago. It's like you start to feel better with the ECT, and then release you and then-the last time when I went back in the hospital and it was an unpleasant time for both of us, and I guess I felt like I did not have the same emotional resources this week that I had two weeks ago. It's been a long two weeks. [00:02:20]

And so it seemed like a concerning idea to do this, not that she actually has any control over it, other than saying whether she's suicidal or not, that's been a whole mess. So that didn't average out for a while-call representing my concerns but Tanya is, perhaps, hypersensitive to me being upset, and whenever I'm upset she assumes I'm upset with her, it's just how that goes. [00:03:04]

And so she can't leave that piece alone, or couldn't leave that piece alone, and kept asking me if I was angry with her, which, after a certain point I became angry with her for having to ask but-so we sat in relative silence for a while and then it became clear that the best answer was for me to go away and (inaudible). I couldn't really talk without saying things that were angry, and not helpful, and so it was just better to end that visit so we did. But I went for another long walk. Went home and went to bed. [00:04:00]

(Long pause 00:04:05) Then got up and, you know, dealt with the anger some more, and that was more or less okay, but eventually I became resigned to: this is what is going to happen. And Tanya had seemed okay and so I made contact with her by e-mail, and talked with her on the phone, visited her again yesterday, and she seems-This was not the point of being angry with her, but she seemed-in an essential sense unflustered by it, which is a really good indicator that she's doing okay, because she can't handle me being angry with her at all. Normally under-I don't know what normally means-under a bad circumstance, she can't handle me being angry with her at all. We've talked about this before. [00:05:00]

And so, [but I think] (ph) in essence we have a fight and she's okay so-but kind of a good indicator that she's actually okay, so that's good.

THERAPIST: But-(pause)

CLIENT: I mean I still have great concerns about this, whatever you call it. It's not really a treatment strategy, so whatever it is, whatever we are doing, it seems problematic. It doesn't seem-it didn't seem like given the way the-given where we are, there's not a clear, better option. [00:06:00] So we continue doing the ECT as an outpatient, which is fine. I kind of think it's been helpful, so that's a good thing. This is a direct path to hospitalization back in the same place, which is good, but we really don't have take it because it's not like that does anything other than get her back to not being suicidal, and put us right back here so (long pause 00:06:30).

[00:07:15]There's something which I proposed to my friend, Franco, that given that Tanya had gotten really bad really fast, in a few days, it ought to be possible for her to get much better really fast also, just from a (inaudible) mechanism, a mechanism of all the work in both directions. Most things do, as a chemical nature, most things do.

THERAPIST: Is that true?

CLIENT: Yeah, in a mechanistic sense it's called the principle of microscopic reversibility, so the mechanism of counter-reaction has to be able to operate in both directions, or else it can't be the mechanism, is basically it.

THERAPIST: Hmm?

CLIENT: Because you have to travel along some potential energy surface, in order to get from products to reactance. So you have to be able to traverse the same path in the opposite direction. [00:08:06]

THERAPIST: Hmm!

CLIENT: It doesn't have to be downhill, or (inaudible 00:08:08), so it doesn't have to happen, but has to be-it has to exist. So, yeah, when we get up to the scale of brain, so I don't know if that matters anymore, so maybe it's not true at that level but-

THERAPIST: And we are asking is this true on the chemical level, I was interested in that bit.

CLIENT: Okay.

THERAPIST: Before you even made the analogy, but yeah.

CLIENT: Okay. (Long pause 00:08:42) And so there's the sense of which like, "This is nice," and again I said, "Look, this is really (ph) possible," and she's dramatically better, like she's just so much better that it's actually disconcerting. Disconcerting when she's more or less okay, and really not okay suddenly, because it's, I'm watching something, and like I'm watching her, and her mood changes faster than I can keep track of. Like I can't stay up-to-date with where she is. [00:09:20] And so going in the other direction is just as disconcerting. I wouldn't have thought it would be this disconcerting, but it is. It's a sense in which, like, it's hard to believe that it's real. Yeah. So she seems a whole lot better, she seems like herself, but how long is it going to last. (Pause) [00:10:00]

THERAPIST: Can you say more about feeling angry, after that phone conversation on Monday?

CLIENT: Yeah (pause). Do you want how it felt? Because I'd give you one sentence (ph) for angry, but I know if they are illuminating-

THERAPIST: Whatever you-?

CLIENT: Okay.

THERAPIST: I wanted to know more about that, whatever you feel.

CLIENT: Okay.

THERAPIST: It's important to talk about it. (Long pause) [00:11:00] I can really be angry and I'm fine, but I was very, very angry, just-We've moved all of our stuff when Tanya's sister was here and so that'it's a vacation that we have, a small one, and so I'm in the process of putting all of the things away, moving things around, and so there's a whole lot of plates and glass, fragile things everywhere. And when I'm angry I have a heavy-a strong desire to smash things, which I never do, or almost never do, and didn't here, but it's full of reasons to go for a walk, and that is also a physical outlet of some kind. [00:12:09] It's just like the intensity, the emotion, yeah, demands some sort of release.

To go for a walk is better. The other thing about it being so intense is that, yeah, just flows over in every direction, in a sense, it's not really critical and I'm actually angry with in the moment, just very angry, and so I can be angry with anything; if that makes sense. [00:13:08]

CLIENT: Mm-hmm.

THERAPIST: Okay.

CLIENT: (Pause) I think there's also a sense (inaudible 00:13:21), when I'm that angry I recognize things that I'm angry about that I have not been-or that I might be angry about that I've not been feeling angry about. There's a real sense in which not only has Tanya been asking a whole lot of me, recently, the sense of which has been extorted from me at the threat of her dying, right, of her killing herself. And so that's not-I certainly don't believe that that is her intention anyway, but that doesn't make it less true that there's some merit to that description. [00:14:14]

THERAPIST: I can understand why you feel that way. (Long pause 00:14:30)

CLIENT: (Long pause 00:14:58) At this point my residual frustration has settled on the structures that exist, the insurance companies, the way that outpatient treaters (ph) have no access to patients when they're inpatient, which makes actually no sense when you think about someone is in their worst place, they probably need the person who actually has a case history with them, in most cases. [00:15:22] Those sorts of things are just the way human systems end up working when a whole lot of money gets involved, somewhat inefficiently.

THERAPIST: Yeah. And as I'd say-the practicality of it, I want to know more about your case, but I see patients in the hospital, the mental (ph) hospital. I go visit them, I can even co(inaudible 00:15:40) for them if I need to.

CLIENT: Really?

THERAPIST: Yeah. I haven't had that experience in years or so, but certainly, yeah. There's actually a co (inaudible 00:15:50), and sometimes I don't really care. I just don't want to see them in the hospital (inaudible 00:15:50). Obviously, I get paid for my work, but no.

CLIENT: Sure.

THERAPIST: This is also-

CLIENT: Also you do you work because you want to get the-

THERAPIST: Yeah. Both-well, hopefully, right? [00:16:00]

CLIENT: (Laughing)

THERAPIST: There's a lot of ways to make a living.

CLIENT: Yeah.

THERAPIST: But even beside from that I have certainly (inaudible 00:16:06) before, I don't think that's successful. I don't know-it's many years as I mentioned. But anyway, I'm not sure that that's really your point, but that has-I've certainly done that.

CLIENT: That is interesting. Did you have to have any special-raise it with the hospital, or did you just-?

THERAPIST: No. I called them up and told them I was coming.

CLIENT: Oh. Interesting.

THERAPIST: A lot of times they're delighted. Do you know what I mean?

CLIENT: Yeah. Sure.

THERAPIST: Yeah, someone else-Anyway-

CLIENT: Well that's very interesting.

THERAPIST: (Crosstalk) I think your observation, in general, as true though, and I think that once the person is an inpatient, the outpatient therapist tends not to have a whole lot of say, that they sort take over and then they are the captives, and the outpatient therapist has to-is more in a less powerful position.

CLIENT: Can call and say, "I'm coming," but other than that-

THERAPIST: Right.

CLIENT: Yeah. It's occasionally consulting.

THERAPIST: Mm-hmm.

CLIENT: As far as I can tell how it goes.

THERAPIST: I think that's true, but maybe that's-Again, maybe I'm getting away from the (inaudible 00:16:58).

CLIENT: That's okay. [00:17:00] No, that's interesting. The more I know about all these things the better it is in some sense. I really (ph) know enough to think that it doesn't work very well, so the other pieces are good. So my frustration is-the residual frustration has focused on, in some ways, where it belongs, in the insurance company driving how the treatment goes, in a way that is-in a financial sense makes perfect sense, right, because in a sense everyone is paying. In an ideal care sense, doesn't make very much sense. It does not make much sense to release your patients and have them back a week later. That's just starting to be a new marker for how you tell if the hospital is any good or not, and if they're going to get their patients back within a certain time window, more frequently than the average amount. [00:18:00]

Of course big hospitals like Walter Reed have problems because they have, of course patients, but more outpatients. And Tanya is not the only patient there on the short-term unit who was there a week ago, and released. So this is clearly a general problem on some level of life. We get them stable, we send them away, they come back because they weren't really stable, they were stable at that moment but-(pause) at any rate, but maybe I'm drifting. I can talk about that for a lot longer, but that's not really the point. The point is that, because that-I can deal with that frustration it's just systems inefficiency, which is very frustrating for me, but I'm used to, kind of everywhere. [00:19:00]

And so it's a little hard to remember everything that I was angry about when I was very angry, because I have worked through it or whatever, to get to where I am now, but I think a lot of it was feeling like more is being asked of me than I can handle. Because I do think there is a non-negligible probability that not high, but not like negligible, that Tanya will get very bad again within the next week, and that's a lot of emotional strain. [00:20:00] It's a lot of time, it's hard. And obviously it's hard on her, but it's also hard on me.

THERAPIST: Yes.

CLIENT: And on Monday I did not see how I was going to be able to do that again, (pause) and then feeding back into that is concern that I'm going to cause that to happen by being concerned that it's going to happen.

THERAPIST: How would that happen?

CLIENT: Well Tanya and I have this relationship that has, like each of us is concerned about how the other is doing. And so if I'm concerned about how she is doing, then she sees me as being concerned, and that makes her more concerned, and so there's this negative feedback that-particularly if Tanya is not that stable, can be bad. [00:21:00] So that's the sense of-in a mathematical sense there's feedback between our functions.

THERAPIST: That's how you're defining cause (ph); got it.

CLIENT: Yeah, yeah. That's right. Fair enough (chuckling) (crosstalk).

THERAPIST: Suppose you had-(crosstalk 00:21:14) whether that's causal, there's effect that made an impact, but whether you caused it, is a little different.

CLIENT: (Laughing) Absolutely, no-

THERAPIST: It's an important distinction though.

CLIENT: Yeah. It is very important, and it's like cause is a really tough one. There's a field of Causal Inference with a capital "C" and a capital "I" at least that's how everyone says it, but has very, very, very vigorous standards to what accounts for the cause. In that, walking away from that in my experimental life, when you do something and it has an effect, it's loosely a cause, so no, but not solely cause it, but contribute to it. [00:22:00] There's a sense in which I am always going to contribute something to her mood that I cannot control, right, and that's fine. The problem is when I feel like I can or should be able to control it. Again, it's still contributing.

THERAPIST: And by saying that, there's something that you can't control that's going to contribute to your relationship, I mean that's called a marriage.

CLIENT: (Laughing)

THERAPIST: The problem in this particular case is the stakes are so high in that impact.

CLIENT: Right. (Pause) Yeah. The stakes are very high (pause) [00:23:00]. Then there's the other place where Tanya is getting is so much better, so quickly, it's disconcerting because the stakes, I think, are much lower than they looked like they were to me at one o'clock on Monday, when I hadn't seen her yet. She had another course of ECT in the morning, and was feeling much better on Monday than she had been on Sunday.

Sunday she had been fine, but I would not have wanted to release her from the hospital on Sunday night, and so that's the last time I've seen here, and talked on Monday, and they're seeing her, whatever assessment they're doing, that she doesn't want to kill herself, we're going to have to push hard to keep her here until Wednesday was there for you because their insurance (inaudible 00:23:56) slip off. She seemed fine right up till we (ph) saw her Tuesday. [00:23:59] But I think that the social work fought very hard to get her to stay in through today so that they could do another round of ECT inpatient, which I appreciate. It's a good thing [00:24:13].

THERAPIST: (Pause) Well, I can appreciate how you feel. I agree-both that individual people and that no one in particular, because you didn't sign up for this. Tanya didn't sign up for this, you didn't sign up for this, and there is no one in particular to blame for it. And sometimes there certainly feels like particular people to blame and it's probably an accurate assessment, but in a much more general sense, who is to blame for this?

CLIENT: Yeah-No, that's right. That's right. In answering that question I could march out a series of people who contributed in one way or another to the issues that I think Tanya has, and then the where she is now, but I don't think that even-but I don't they are to blame. [00:25:12] Certainly none of them, individually, has caused the whole thing. And so, yeah-no there's not a clear person to blame.

THERAPIST: And the situation has-or her state of mental health has changed dramatically. You always knew she had this tendency of depression and you knew you should have signed up for this, but her getting this sick, I don't think you could have anticipated happening.

CLIENT: Yeah. I could quibble what could have, but I certainly didn't, and I think it might have been possible for a human to guess that this could happen, but-

THERAPIST: You could spend all your life-[00:26:00] I mean I guess that's true-

CLIENT: But beside-

THERAPIST: I wouldn't encourage that exercise though.

CLIENT: (Laughing) Fair enough. Yeah, it's not very meaningful to say that. Yeah-no, did not anticipate. Could not really have anticipated-Yeah, I don't know whether it would have been possible to anticipate this whole set up (ph), maybe. Certainly I would have needed a lot more training in-very different fields that I have to do that, and yeah, it changes the stakes in a very, very radical way. It makes it not just debilitating, or hard, it makes it life threatening. Yeah. [00:27:00]

THERAPIST: Has she attempted suicide before?

CLIENT: She has not yet attempted suicide.

THERAPIST: Has she had plans?

CLIENT: Yes.

THERAPIST: I see.

CLIENT: Yeah. We've had a tier two a few times, yeah.

THERAPIST: Tier two is the plan?

CLIENT: Well, people always ask, "Do you want to hurt-do you want to kill yourself? Do you have a plan?" And then presumably tier three is an attempt, but no one has actually called them tiers. It's just the way the questions get arranged. Yes. So that if she'd gotten-each of the last three hospitalizations I think she's had a plan. Maybe this last one-the one last week she didn't have a plan, it was just she would have a plan by the time we got home, I think, if we'd gone home. But none of that-all of that is new in the last couple of years, so that wasn't[00:28:00] (Long pause 00:28:54) There's this real sense of what should I-I'm not convinced that at this moment she's aware how bad it was a week ago. [00:29:04] She may well be fully cognizant of it, but it's a little hard to see her, how she could be fully cognizant of that and (pause) in a sense really want to go home and feel like that's an okay thing to ask of me. I certainly understand her wanting to be at home, and this is still like-I'm not as concerned about this today, I certainly was Monday. [00:30:00]

THERAPIST: (Pause) And is a piece of that, you're feeling that she's not aware of how much she's asking from you? Do you feel that that's a piece of it, in terms of saying that she didn't realize how badly she was doing?

CLIENT: Yeah. No-and I think if she can't remember, but so clearly how bad it was, then she doesn't-then she can't have so clear a picture, yeah, of what she's asking of me in dealing with that.

THERAPIST: (Pause) I have so many different kinds of thoughts, and I also want to stay with you in your thought process, so I'm kind of going in a couple of different directions, but my first and a very practical thought is if she's out today, have you thought about whether you want to her to come next week, and what you'd like to do? [00:31:10]

CLIENT: That's a really good question. I haven't thought about that much. It has crossed my mind and will have to figure it out, what to do, but (pause) yeah I really don't know. My thought-I don't know-a week or two ago, was that what we needed at the moment was not couples counselling. I think it's some professional support, and she needed some treatment or support, or however you want to phrase it. And so the couples therapy thing didn't seem to be that important, and so it seemed like, "Well, let's just-" [00:32:09]

Obviously we've been making decisions, but it seemed like the straightforward thing to do was to have her continue seeing Chad, and (inaudible 00:32:17) her psychiatrist. And then for me it comes to you, and then pick up with the couples counselling again, which she was better-this is a real sense when she's better, don't know how long it's going to last, but today she's better. So I don't know where that leaves us.

THERAPIST: Well couples counselling-and this is not to say it can't work for both of you-but couples counselling, in terms of traditionally conceived as just off the table, it makes no sense. I mean I was actually thinking about this a few weeks ago, so I typically don't see people in a case of domestic violence, because if there's a threat of injury because of what comes up in the treatment, that makes no sense. Like I'm not going to see-Do you see what I'm saying? [00:33:00]

CLIENT: (Crosstalk)-

THERAPIST: This is actually analogous, except the threat of injury isn't to you directly it's to her.

CLIENT: Right.

THERAPIST: So essentially if each person-if it's too overwhelming what might come up in the context of the treatment, then that's not good, right. I need to know that people are safe from week to week in a very basic way. So in a really traditional sense, I couldn't do that, right?

CLIENT: Sure.

THERAPIST: Now that's not to say that the two of you can't benefit from support together, and send even just practical support, and that way it's more like an-Have you gone to the inpatient unit? Have you met with social workers and things like that?

CLIENT: Yeah. I have. And it's different at every place, so I have not met with the social worker here except for discharge planning. But at Mount Sinai where we were the last time, I remember the social worker on intake also.

THERAPIST: So that will sort of-goes against what I said to you guys at the very beginning where I think it was less clear to me how troubled Tanya was and how severe here symptoms was, that it would probably mean more of a focus on her as a patient, on how the two of you are going manage that. [00:34:02] But I think that that's really-I don't see how working with the two of you I conceive of anything other than that. I mean how the two of you get along in terms of working on your communication and so forth. I mean this seems (inaudible 00:34:13) under the circumstance.

CLIENT: (Chuckling)

THERAPIST: That's not to say that I couldn't be a benefit for the two of you, but I feel like that would be more my framework. So that's one thought. The other thought I had is unless-even though I'm not uncommitted to it, unless-I certainly would-if she was adamantly opposed to it, I would not go along with it, but I'm a little less committed to her full-fledged support for this particular reason. That I feel like in the system, you have felt very much like you've had to subjugate your needs to her treatment, and so the concern is, if she said, no, and then you went along-said, "Okay, well I'm not going to continue to see me," it would be a replication of that in some way. That would be my concern. Now this is all hypothetical because I don't know how she feels but[00:35:00]

CLIENT: Yeah. And I'm not exactly sure how she feels now either. No. How she felt three weeks ago and how she felt two weeks ago, and they didn't match perfectly, so I don't know really know how she's going to feel now. I understand the concern you are raising and it's not crossed my mind in that framing but, yes, that has crossed my mind also. That there's a real sense in which the question I usually try to answer is: what does Tanya need? And there's a question here what do I need also, that I need to answer. It's a hard question to answer. It's a very hard question to answer, for me particularly, but I don't know if I'm special in that regard, if that's just a generally hard question for people to answer. Yeah, it's hard. [00:36:00]

There's also a sense in which (long pause 00:36:24)-I don't want to make a demand or say, "No. This is what we have to do," to Tanya, because in a sense that would be doing to her what has been done to me, by her illness. So certainly-it's a decision I feel like we need to make together, but it doesn't have to-it doesn't have to have the outcome of her needs are superior; if that makes sense.

THERAPIST: Well one of the big, sort of, from a practical level, and having to (inaudible 00:37:01) guys and have a conversation about this. [00:37:02]

CLIENT: Okay.

THERAPIST: I think this could be a really important conversation, not from only a practical perspective but just the underlying issues. So I should say that, ahead of time; that I'm happy to do that.

CLIENT: Okay.

THERAPIST: In other words, I understand (ph) what you said, you don't want to sort of make it categorical, but it is in-the roles would be reversed but it's the same dynamic. But I do think it speaks to the heart of the issues is, sort of like, at what do you put your needs-at what point is it not negotiable, where your needs are expressed. What you're saying is you've felt, and understandably so, I think this accurate perception of the situation, that this has been, not negotiable. Like, "This is what Tanya needs. This is what's happening." It's not negotiable, what you need is-you haven't been checked in very much around that, to some extent. There's a little bit of manoeuvrability, but not a whole lot of flexibility in that.

So in my framing the problem that way, it is just like, how can the two of you exist in a way, each of you individually and together where, at least in this particular case, her needs don't trump yours, or vice versa. [00:38:08] That there's some manoeuvrability in a very difficult situation that's already sort of imposing a lot of rigidity.

CLIENT: Right. (Pause) I think that's the correct question, I'm going to have an answer to it, but there's kind of two answers, one is that she and I talk about it, and one is that we talk about it with you.

THERAPIST: And I'm fine with it either way. I mean I don't have a strong preference.

CLIENT: And I think that the-I think there's a sense in which it comes down to whether Tanya needs to talk [about this] (ph), a ridiculous cycle, but whether needs to talk with you about it also, or not, in order to feel like a part of the decision-making process, or feel like she understands what decision we are making. [00:39:09]

THERAPIST: In term of the negotiability of needs, I think this sort of a heightened situation, but all couples face this. One couple wants to live in this part of the country; one partner wants to live in the other. You've got to figure it out because those needs predominate as one person's need, less negotiable than the other. And this is where an ongoing tension of being in an intimate relationship.

CLIENT: [That's right] (ph)

THERAPIST: But there are certain things that raise the stake more than others and make it feel less negotiable.

CLIENT: Sure.

THERAPIST: The other thought I had, and I was really-I think it's an important distinction; it is at some point, hopefully soon, when we do make a decision, it matters because my focus is very different. When I work with you individually, I really think about what's best for you, and what's best for you, may not necessarily be what's best for you as a couple, it may but it may not. I mean, it sort of gets to the heart of what we are talking about. [00:40:05]

CLIENT: Sure.

THERAPIST: And so it's-from my perspective, it makes a difference because it really-it's a different set of-needs that are prioritized. And when you are my patient, you are my client, but what you need is what we think about, and what you need is to be responsive to Tanya's needs. That's a piece of it, but-

CLIENT: Right. But it's not the only piece?

THERAPIST: It's not the only piece. It is a very different focus. So that's really the distinction I make more than anything else.

CLIENT: Right. Well, I'm seeing whether (inaudible 00:40:43) shows up or not, it's an important distinction too I think.

THERAPIST: Right. But you see that that's also an important piece. Even, I've had an eye to this. Even when I'm working with you individually, if I still think about Tanya as piece of it, it's still slightly a different focus even with her not being here. [00:41:05] And I also feel working with the two of you, how her treatment is going is a little bit more on my radar than if I'm working with you individually. Not that I don't care about it, but it's-obviously it impacts you, but it's less on my radar. I feel less invested in it. Not to say that I actually feel like I have any capacity to impact it in a meaningful way, I would if I did, but it's my-I guess this just sort of the same thing, and my focus is somewhat different.

When I work with somebody who first comes to me with an ill spouse, I don't necessarily think about how I can help that treatment of that spouse. I think about: what is it like for you and what can we do about your conflicts and dilemmas and so forth around having an ill spouse.

CLIENT: Makes sense. (Long pause) [00:42:00] Do you have a recommendation?

THERAPIST: Yeah. I have a slight, I would say preference. Recommendation sounds-well, I guess maybe recommendation. I think we should continue to work, the two of us. I feel like we've developed a good rapport, and I feel like I can really help you, and I do see that there's more merit in this right now than me working with the two of you. Not to say there isn't merit in that.

CLIENT: Okay. That is the way I feel also. (Pause) I feel like what you just said, has some weight, and so would like to have-I like to have input where possible when making decisions like that.

THERAPIST: Well it has weight further-I mean it probably has weight for couples in different ways if-and it certainly does happen where I end up starting meeting with a couple and meet with the person individual for a whole host of reasons I'm sure. But it has [way bigger] (ph) the particular significance for your own conflicts, and then for your relationship, but what it-but part of it is, what does it mean for you to make decisions and take care of your needs when it may or may not be in accord with what Tanya needs. [00:43:21]

Which again, I don't even-I'm sort of talking about in the hypothetical, but then that's part of the reason it has weight.

CLIENT: Right. That's right. That's exactly right. And I don't have a really clear sense of what Tanya needs at this point. In a sense it may be a non-issue. She may feel like it's much better from her perspective for me to be seeing you, than for me to not be seeing anyone else; or something like that.

THERAPIST: Yeah. I wouldn't be surprised if it was her perspective since she was-she came in and one of her concerns was (inaudible), right?

CLIENT: Right. [00:44:02] So there may not be any issue at all in terms of balancing each side.

THERAPIST: (Pause) In this case?

CLIENT: In this case, yeah. And I was just thinking that, (inaudible 00:44:29) actually concerned will become having the conversation with her.

THERAPIST: Sure.

CLIENT: I was a little anxious the last couple of times we talked about it because there's a real sense of what she liked. I never know quite what she's going perceive as abandonment, because it doesn't always-like I told you her psychiatrist was sick and we didn't get the message. So she shut up, and I really think she felt abandoned although-but I didn't get a clear statement of that from her. Her response in terms of its degree seemed like[00:45:02]

THERAPIST: It took a guess on your part.

CLIENT: (Chuckling) But for me, that's not abandonment, right, that's just, "This person isn't aware of it." It doesn't-it's not a trigger for me. It's a little bit harder to pick out what the-it's upsetting, sure, but it's not the same sort of trigger. So it's kind of hard to pick out what is going to hit that button and what's not.

THERAPIST: Which is itself, a different version of the problem, it's do you feel like you need to very carefully avoid triggers and things like that?

CLIENT: (Chuckling) Yeah.

THERAPIST: And that's a piece of it that makes you feel a part of what makes you feel like it's extortion, or at least at times.

CLIENT: At times, yeah. I definitely do at times. And really don't at other times, when I don't have a clear sense of when or why. And sometimes I (pause) don't particularly mind it, but look at it and say, "Well this is effectively extortion in some instance. [00:46:09] Like I don't feel it to be, but can recognize it as that or something.

THERAPIST: We are going to need to stop for today, so whatever variation you guys come-this is your time.

CLIENT: Okay.

THERAPIST: If you need to talk to me before, you can call me. We can sit down and talk about it, whatever you need, just let me know. Okay?

CLIENT: Thank you.

THERAPIST: Okay.

CLIENT: All right. I will. See you next week.

THERAPIST: Okay.

CLIENT: We'll let you know before we come, who is coming.

THERAPIST: Okay. Take care.

CLIENT: Thanks.

THERAPIST: Bye.

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