1. Major Complications to Cple Th - RonaldMah

Ronald Mah, M.A., Ph.D.
Licensed Marriage & Family Therapist,
Consultant/Trainer/Author
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Opening the Can of Worms, Complications in Couples and Couple Therapy
Chapter 1: MAJOR COMPLICATIONS TO COUPLE THERAPY
by Ronald Mah





**Author’s Note: Other than public figures or people identified in the media, all other persons in this book are either composites of individuals the author has worked with and/or have been given different names and had their personal identifying information altered to protect and respect their confidentiality.  

Molly had a problem at work.  One of the newer employees was given a prime assignment that she thought she deserved.  When she told her husband Cole about it, he asked if she was in good standing with her boss.  She said she was.  She'd been there for a long time and had a lot of important responsibilities.  Her last review went very well.  Molly had gotten a raise recently.  Her boss had pointed her out as an exemplary employee when the big boss visited the department.  After asking some more about her value to the company and her relationship with her boss, Cole came to the conclusion that "Molly, you don't have anything to worry about.  Relax."  Cole described it later to the therapist, "It was like I sold the children, flushed the wedding photos down the toilet, or abandoned her to slave traders!  She exploded on me!  She screamed that I was a jerk… an insensitive jerk.  That I never… NEVER support her.  Damn, I knew I might not get this 'supportive' stuff right and catch a little flak, but damn I didn't think I'd get nuked!  I sure as hell didn't think I should have gotten massacred for trying to help."  Something small and seemingly insignificant turned out to be huge, ugly, and explosive.  Cole added, "It should be simple.  Molly tells me about a problem.  I listen… and I do listen.  And then give her some feedback… an opinion.  But damn, it gets crazy.  Don't get me wrong, this don't happen all the time.  That makes it worse kinda, cause then I don't expect it.  But then I step on some kind of emotional landmine and I get blown to pieces!  I say anything and it opens a nasty can of worms."

Molly has a problem at home.  There are other times she gets annoyed that Cole does not get it.  As she tried to explain how she felt slighted, Cole just could not make sense of it.  Molly ended up feeling dismissed.  Then she got mad at Cole.  Now, he was really sure that Molly is irrational.  She got upset over nothing serious at work and then, she got mad at him for pointing out her illogical reaction to the situation.  From perplexed at her line of thinking, he got upset at being "crucified" for being logical.  He argued how she's doubly illogical.  And he's mad about it, but his anger is justified unlike her anger.  In therapy, Cole tells the therapist that his wife Molly is too emotional.  He is logical while she is illogical.  Molly asserts the importance of her perspective and the associated feelings.  In fact, what is important about her perspective is the emotional valence attached to it.  In fact, Cole not getting her and his disagreement with her is important because he is her husband.  If it were almost any other person, it would not be important.  

The therapist frequently finds that a couple does not readily fit into some model of therapy or respond to common interventions and feedback.  Of course, Molly "over-reacted" to Cole's response.  The therapist could guide Cole in how to communicate with Molly.  And take the chance to challenge Molly's reaction as excessive.  If the therapist judgment and action so limited, then Molly not only had a problem at work, that became a problem at home with Cole, but now Molly has a problem in therapy with the therapist!  The therapist cannot just conduct "regular" therapy when major complications exist in the couple or one or both partners.  1 + 1 + 1 does not equal 10.  The couple's can of worms is open and there are lots of slimy issues to deal with.  There was one- the situation at work, another one- Molly wanting something from Cole, and the last one- Cole trying to give Molly what she wanted.  Instead of adding up, it went crazy.  However, psychological algebra knows that 1 + 1 + 1 = 3, not 10.  What makes it add up?  It has to be some "X" factor.  Basic psychological algebra says 1 + 1 + 1 + X = 10.  What is the X that makes it make sense?  What is the underlying or other issue… the compelling factor that caused Molly to become so hurt and then, so angry?  Metaphorically, that is the task of diagnosis in therapy.  What should work will work!  What should work will work… unless there is more to it.  Molly is not crazy nor is Cole.  Something or some things have complicated what could or would otherwise be relatively simple.  Couple therapy that does not find and open the partners' can of worms is simpler to conduct.  However, couples without complex underlying issues probably do not need to come to therapy.

The therapist should anticipate or be on the alert for various complications in the couple therapy.  Complications or challenges can overwhelm the therapist and frustrate the couple.  Yet, to the experienced couple therapist such complications or challenges are not extraordinary issues but commonplace when working with couples.  If they do not exist, the couple would have arguably been functioning sufficiently successfully or productively enough not to need the assistance of couple therapy.  A couple such as Molly and Cole are sensible enough to communicate reasonably, follow boundaries, and otherwise operate functionally.  And, they usually do so effectively and efficiently.  That is, they do until they don't!  In their life and relationship issues arise or intrude from beneath the psychic surface to make easy living difficult if not impossible.  In some situations, complications or issues arise within the process of therapy and other times, individual issues had complicated the couple's relationship and then complicate the therapy.  More often than not, there are multiple dynamics that contribute to relationship dysfunction and the complex therapeutic process.  There are arguably minor complications that an individual can successfully deal with.  However, the distinction between a set of major to supposedly more minor complications to the couple's relationship is questionable.  Often minor issues become major issues over time and/or with other contributing factors.  Since the issues interact in complex, nuanced, and fluid ways to influence emotions, thinking, psychology, spirituality, and behavior, the therapist is tasked to determine the most relevant issues from the spectrum of possibilities.

The therapist overtly seeks and opens the can of worms.  Some issues may be less influential.  However, for an individual, couple, or family, one or more of those issues may be the major influence or influences upon their processing and functioning.  This book examines some of the major complications or issues that commonly are of extreme impact upon an individual, couple, or family.  In particular, issues that involve high emotional reactivity are considered.  The therapist will often find that exploration in one or more areas will direct further examination of important, experiences, conditions, and disorders.  Jansson et al (2008) makes recommendations about the co-morbidity of important issues for appropriate treatment.  "The findings indicate that patients with conduct disorder and borderline and narcissistic features were likely to experience unremitting psychiatric symptoms that should be the focus of aftercare treatment for these patient groups.  In light of findings such as these, personality disorders might be considered comorbid problems of substance-abusing women along the same lines as psychotic, anxiety, mood, and bipolar disorders; that is, disorders that deserve special attention in their own right, rather than simply  'indicators of poor prognosis.'  Psychiatric symptoms are associated with intense subjective distress and human suffering, and should be the target of treatment" (page 175).

The therapist needs to give due attention to any relevant issue that for its impact on an individual and the couple.  The therapist and the professional community have found that certain experiences, conditions, and disorders have historically been profoundly and negatively impactful on intrapersonal and interpersonal functioning.  This is a search for the "worms" within the boundaries of the partners.  They are commonly important underlying issues.  By virtue of extreme consequences on an individual and difficult intrusive consequences to relationships, such experiences, conditions, and disorders have been the object of research and codified in professional literature.  Certain conditions are considered neurological or genetic that an individual are born with and persist throughout life.  These include learning disabilities, attention deficit hyperactive disorder, attention deficit disorder, Aspergers Syndrome (or a form of high functioning Autistic Spectrum Disorder), and gifted abilities.  Already challenging to the individual, they can further adversely and severely affect individual development if not addressed.  While such issues or conditions are considered enduring and cannot be eliminated or "cured," they are amenable to compensation.  They can subsequently affect relationships- often without either partner's awareness.  Chronic depression and anxiety may be temperamentally intrinsic to some individual, with lesser or greater sensitivity and vulnerability.  On the other hand, formative and ongoing experiences can cause an individual to develop chronic depression or anxiety. Living with depression or anxiety burdens the individual.  Living with an individual with depression or anxiety burdens the partner and challenges the couple.  Borderline and narcissistic personality disorders in particular fundamentally challenge intimate relationships. Dependent and histrionic personality disorders also affect relationships detrimentally but possibly in more subtle less overtly toxic ways.  On the other hand, paranoid and anti-social personality disorders intrinsically push the boundaries of assertion, aggression, and abuse in couples conflict that lead to domestic violence.  It is further arguable whether addiction or affairs are consequential to problematic relationships or the complications the corrupt intimate partnership.  All these issues involve or can exacerbate emotional volatility that breaks down mutual reciprocal interaction, and thus, intimacy.  For individual books dedicated to more in depth examination of each or important groupings of these major complications to couples and couple therapy, see the other Books by Ronald Mah descriptions on the website.

This book examines major challenges to couple therapy from high emotional reactivity including consideration of three major complications or issues: bipolar disorder, post-traumatic stress disorder and trauma, and personality disorders in general.  These and other complications function virtually as intrusive third partners in the couple, interfering with the best intentions of the two partners.  The challenge relevant to such experiences, conditions, or diagnoses and to others are high emotional reactivity.  Out of control emotions can waylay interpersonal interactions, dynamics, and intimacy for individuals with bipolar disorder, trauma experience, or a personality disorder.  An individual may have multiple issues that mutually exacerbate dysfunctional emotional reactivity.  Out of control emotions that corrupt the couple's relationship may manifest in therapy to also frustrate therapeutic guidance and interventions.  The therapist may find "calming down" the session as difficult as "calming down" the couple.  Bipolar disorder is included in this discussion because it shares high emotional reactivity within its manic and depressive states with substance abuse, post-traumatic stress disorder or trauma, and personality disorders.  Consideration of bipolar disorder is instructive since emotional reactivity from bipolar disorder is considered non-volitional.  A person deep in either the manic or depressed phase will be emotionally intense and volatile as a result of biochemical and neurological processes not under cognitive control.  Under the influence of substances, emotional reactivity can also be considered non-volitional.  Drug influence on the brain overrides higher cognitive functioning- for example, inhibitions with alcohol and activation of a spectrum of psycho-physiological arousals with stimulant drugs.  However, substance use, abuse, and addiction along with behavioral addiction are considered anywhere from highly volitional to highly non-volitional depending on theories and moral judgment.  The recommendations for treatment of bipolar disorder are instructive to dealing with PTSD and trauma and personality disorders because of the assumption of high emotional reactivity being non-volitional.  PTSD and trauma and personality disorder behaviors are similar to substance and behavioral addictions in their conceptual ambiguity as voluntary or compelled.  The consideration and treatment of high emotional reactivity shifts significantly when it is no longer considered to be strictly volitional.  Indeed, the effectiveness of therapy may come from being able to distinguish what degree of control can be achieved and over what aspects or expressions of emotional reactivity.


ADDRESS:
433 Estudillo Ave., #305
San Leandro, CA 94577-4915
Ronald Mah, M.A., Ph.D.
Licensed Marriage & Family Therapist, MFT32136
CONTACT INFORMATION:
(510) 614-5641 or (510) 582-5788
fax: (510) 889-6553
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