Therapist’s Notebook

Editor’s Note: Cases are fictitious. Any resemblance to actual clients is coincidental.

Case of Glorya and Sid
By SaraKay Smullens, MSW, BCD, LCSW, CFLE, CGP

Glorya and Sid consulted me due to ongoing tension and friction in their marriage. Both were angry at their lack of desire for any kind of sexual intimacy and sharing. They were articulate, intelligent, competent professionals. Though not naturally introspective, it was apparent when a question was posed to them that their ability to think psychologically was strong. Now in their early 40s, they met and married while attending a highly competitive law school.

In Glorya’s words, “Everything between us was great until I had our first child nine years ago. As if overnight, Sid morphed into an ‘anything-you-can-do, I-can-do-better’ husband. We now have three children, Time, aged 5; Karen, aged 7; and Cynthia, aged 9. Sid takes delight in letting the kids know he is a better lawyer, better artist, and better computer whiz. Even his waffles have to be better than mine. With other friends and family, Sid is always interrupting me midsentence to put down my ideas.”

Sid countered, “All you care about is that the housekeeper arrives at 8 am so that you can get to your damn law firm. Then when you are home, all you do is concentrate on the kids.” And Glorya responded, “Well, somebody has to care. You wrap yourself in the computer and only join the kids and me to put me down.”

Family History
Glorya’s father abandoned her mother during her pregnancy for another woman. He died when Glorya was 5; she never had contact with him. Glorya explained, “It kills me to see parallels between my childhood and my kids’ childhood. My dad was gone, but theirs is invisible.”

Glorya’s mother began selling cosmetics to make ends meet and, with constant hard work, developed a line of beauty supplies. By the time Glorya was 10, her mother had gone from “rags to riches.” Glorya grew up helping her mother in her five initial stores, “knowing the value of hard work, work, and more work and loving it.”

Despite her loss, Glorya grew up in what she described as a loving extended family, “Even though there was no dad, I was always was with my aunt and uncle and their kids, who were more like brothers and sisters than cousins. They and my grandparents lived only a few blocks away. Still, I always liked to go back to the quiet of a home with just Mom and me.” Glorya’s mother was diagnosed with pancreatic cancer during Glorya’s first pregnancy and died within three months.

Sid was one of three siblings. His younger brother, Jerry, was 11 months younger than Sid, and three years after Jerry’s birth, Amy was born. One day when their mother was walking hand in hand with Amy to the park, a drunk driver ran a red light. They were struck and Amy died immediately. Their mother was in intensive care for two months and finally recovered from massive chest and leg wounds, though her right leg was amputated. She never adjusted to the prosthesis or came out of her depression.

Sid explained further: “My brother and I were more like twins than ordinary brothers. We did everything we could to make Mom happy: good grades, good athletes, good sons. But Mom never stopped grieving for Amy. Nothing we did was enough, no matter how hard we tried.”

His father was a withdrawn man who was, “uncomfortable around any expression of emotion,” according to Sid. A skilled lawyer, Sid’s father was “not one who brought clients to his firm,” Sid explained, “but he was the primary one who did work for the rainmakers and whose skill kept clients happy.” Unable to deal with his wife’s medical problems and depression nor able to mourn the loss of his daughter, he buried himself in his work. Sid’s view of marriage in his childhood home: “two people who lived in their own and joint misery.” His parents now live in a retirement community, “where their unhappiness continues.”

Treatment Approach
Following two initial joint appointments with Glorya and Sid, I recommended two separate groups in my practice, each lasting for nine months. We agreed to meet together at the midway point of the groups, at their conclusion, and at any time the couple and I agreed that such a meeting would be productive. We also agreed that I would meet individually with each one to delineate and draw up contract issues that they would focus on during their group therapy experience.

Sid’s agreed-upon contract issues: 1. Do I still want this marriage? 2. Why is my relationship with my kids miserable? How can I change things? 3. I want to stop falling into my mother’s depression pit and my father’s horrific isolation.

Glorya’s agreed-upon contract issues: 1. Do I still want this marriage? 2. How can I find more strength to cope until this decision is clearer? 3. I eat horribly, never exercise, and want to get back the healthy routine I was in before this marital rut.

Awareness Goals Leading to New Attitudes and Behaviors
Glorya was still mourning a mother who loved and protected her. Her husband’s criticism of her mothering touched unexamined pain about the abandonment by her biological father.

Mourning and abandonment were also a major unexamined component of Sid’s world. He did not know that he had the right to mourn his sister and the parents who abandoned him emotionally when his sister died. Nor did he know that he had a right to feel and express anger at his parents for the pain they caused him or at the sister he believed was the favored child. Sid could not see that the major outlet for his childhood aggression was competition with his brother Jerry, whom he distanced himself from because of overpowering rage he did not recognize or understand. Also, he had no idea that his wife and children were bearing the brunt of his rage, with him wanting Glorya to be the mother he had lost.

The clients in Sid and Glorya’s groups were dealing with recent death: In Glorya’s group, it was a deceased spouse, and in Sid’s group, the death of a child. By the second month, Glorya was able to see a link between abandonment and death. She wept bitter tears for herself and her mother who never showed her the pain and longings she knew she must have had, as her uncle had told Glorya that her mother adored her first love, Glorya’s biological father.

By the third month, Sid began to talk more and more about the loss of his sister, as well as his parents following her death. In his group, there was a young man whose twin brother was serving in Iraq, and the client lived in terror that he could lose him. Sid began to see his treatment of his brother in a new light. He was also able to see his parents differently. Facing anger constructively led to feeling empathy about his mother’s physical and emotional agony and, as Sid described, “sad and frustrated” that they did not get the kind of help they needed. He also vowed to take his family to visit his parents and to be kinder to them during these visits.

By the mid-group session conjoint appointment, Sid had been spending more time with all three children. He was able to tell his wife that he realized he was taking his long-buried childhood anger at his sister out on his own daughters. As he wept, Glorya took his hand. He told her that he thought that their son Tim was “getting the rap I had laid on Jerry.” And, as if I were no longer in the room, Sid kissed his wife’s hand, telling her, “I think you have been getting a triple whammy for my parents, my brother, and my sister. Please forgive me.”

Closing months in groups elicited deep expressions of the loss of needed loved ones and opportunities during youth. It also elicited renewed individual and family hope for the future. This growth and awareness, with accompanying changed attitudes and behaviors, was evidenced in our final conjoint appointment.

— SaraKay Smullens, MSW, BCD, LCSW, CFLE, CGP, practices in Philadelphia and is a recipient of a lifetime achievement award by the Pennsylvania Chapter of the National Association of Social Workers for her codification of cycles of emotional abuse, her development of a treatment model for the cycles, and her continuous commitment to advocacy and activism on behalf of her clients.

Discussion No. 1
By Jeanette Sinibaldi, MSW, LCSW

Marital counseling is a very challenging modality of therapy and is not for the faint of heart. In this country, six in 10 marriages will end in divorce. With a 60% divorce rate, you can be sure that you will be treating couples with marital and relationship issues at one time or another.

In this case presentation, I agree with the analysis of Glorya and Sid’s issues but think that bringing the grief issues to the table will not necessarily resolve the marriage problems that brought this couple to treatment. In their initial consultation, they reported very destructive patterns of conflict. I believe that conjoint therapy would be more effective for them so they can learn how to better communicate. The therapist needs to work with the couple to see how they can move through the process of listening with clear and assertive communication.

John Gottman, PhD, who is well known for his work on marital stability and divorce prediction, has a term describing the prediction of the death of a marriage. He calls it “The Four Horsemen of the Apocalypse,” and it is very aptly put. These four behaviors will sound the bell tolling the death of the marriage. If continued, there will be no relationship left and the couple lives in silent misery, if they can stay together at all. These are often ways that couples cannot deal with the emotion of anger in living with another person and so the relationship gets destroyed. It is essential that a therapist analyzes these four behaviors when observing the interactions of a couple and intervene to promote change in these four arenas.

The first behavior is criticism. The partner attacks the personality of the mate rather than a specific behavior that is annoying. I have called it “character assassination.” An example of this would be someone being upset that the partner did not show up on time, call, or address the issue. The anger mounts to statements such as, “You are so irresponsible. This is how you always behave. You don’t care about anyone but yourself and your things. You are selfish.” We see this style in Sid’s attack of Glorya.

The second horseman is contempt. This is belittling the partner. You may see one partner putting down his or her spouse. Statements are disguised as “I was only kidding around.”

The third horseman is defensiveness. Although this may be something that is instinctive to do in a conflict, it does not help a relationship or communication. One or both partners experience much tension and cannot hear what is being said without making excuses, denying responsibility, or bringing up similar things the partner does in defense of the attacked behavior. The defensive partner will often feel upset and hurt about having the behavior brought up. This is a common way of arguing resulting in continual stalemates. Glorya retaliated in this way with her response to Sid’s attack of her.

The last horseman is stonewalling. This is highly destructive to the marriage. The person is pulling themselves out of the marriage into their own head and not working out the problems. It can get to a point where both partners do this because they can no longer even talk to each other. If you have honest clients, they may even say that there are negative thoughts going on in their head about their spouses that they don’t express openly.

Sid’s apology to his wife was the beginning of his awareness of his personal issues, but his style of communication when conflicts arise between them can be the focus of this couple in conjoint marital therapy. Unfortunately, the recognition of damage done and the desire to make amends will not be enough without the tools to help Sid correct his behaviors. His father set a pattern of stonewalling that gives Sid another negative tool to draw on.

Glorya needs tools to learn how to move from defending herself when anger arises in a relationship. Her emotional support of Sid needs to be monitored so that she does not fall into the trap of mothering him. The therapist must monitor the couple’s interactions in conjoint treatment so that the relationship reflects a team effort involving love and understanding.

When doing conjoint marital therapy, a therapist is a teacher and cannot let couples engage in destructive behaviors. The idea is to rehabilitate the way couples deal with the problems that have led them to your office. Often a new therapist allows couples to argue and fight in their usual way and comment on what has been going on between them. The couple can leave and go home feeling even more damaged. The therapist and the couple will analyze their arguments, and the therapist will continue to point out how their conflict style has done the damage, indicating that their behaviors, not the marriage is the problem. The focus is to reeducate them. Homework assignments on fighting and assigning written arguments, although forced, will change the pathways they have created. This is the first and essential work of the beginning stage of any treatment.

Glorya and Sid are now ready to learn how to communicate in a more appropriate manner and not argue with such critical and accusatory tones. They can enhance on the wonderful work that has already been accomplished.

— Jeannette Sinibaldi, MSW, LCSW, is in private practice in Forest Hills, New York City. She specializes in loss of all kind and also supervises and lectures. She has been in practice for 26 years.

Discussion No. 2
By Barbara L. Holzman, LCSW, ACSW, BCD

What this case illustrates so well is the emotional price clients pay when unresolved loss and grief issues are not addressed and are carried from the past into the present. These clients have been emotionally crippled in their marital relationship by making their past their present. Not only has their relationship suffered but their relationships with their children have been affected as well. Although they recognized the toxic environment in their home, they were unable to change it and therefore sought help.

Both Sid and Glorya experienced emotional deprivation at early ages. For Sid, it was the tragic death of his sister when he, at the age of six, was venturing into the larger world of school and peer relationships, Although his mother was there physically after being hospitalized for several months following the accident, she was emotionally walled off. Neither Sid nor his brother could ever breach the fortress erected by their mother, no matter how hard they tried. She was so enveloped in her agony, anguish, and grief that she was frozen in that place and time and nothing could thaw her out. The life that the family knew before the daughter’s death was taken from them, and any happiness, joy, or pleasure were replaced with unexpressed sorrow, loss, anger, and pain.

Not only did Sid’s mother lose a child in such an excruciating way; she also lost a part of herself—her leg. She was unable to adjust to the prosthesis, leaving her with another unhealed wound. The loss was a constant reminder of what else was gone from her life forever—her only daughter. She was dealing on a daily basis with unresolved physical and emotional agony.

Sid’s father coped with the loss his daughter and his wife through immersion in his work. Work was the drug he used to avoid feeling or expressing what he had so tragically lost. As a result of his father’s withdrawal, Sid’s emotional deprivation was compounded, as neither parent was present for him and his brother. Both parents went through the motions of living but were emotionally detached from each other and their children.

Sid and his younger brother appeared to have only each other for support and comfort. Initially, Sid described how they did everything together and were “more like twins than ordinary brothers.” He couldn’t allow himself to own his anger at his sister, whom he saw as the mother’s favorite until his work in group allowed him to recognize these feelings and deal with how they had been displaced onto his family.

Glorya’s childhood’s also contained a significant loss—that of her biological father. Her mother’s intense focus on work may have allowed her to distract herself from the deep wounds she suffered from Glorya’s father’s betrayal when she most needed and wanted his support and love, being pregnant with Glorya. Even though her mother never spoke of her chronic heartache of losing someone she loved, Glorya was aware of it because her uncle had told her how much her mother loved her father.

In spite of her mother’s deep loss and the wounds that it created, Glorya describes a very close and loving relationship with her mother. Her identification with her mother’s strong work ethic and her involvement in her mother’s professional life was meaningful to both of them. Although Glorya valued the extended family relationships that she had, it appears that time alone with her mother was what she most cherished. The meaning of the loss of this loving and nurturing relationship and the grief it created when Glorya was pregnant with her first child was a buried wound exposed by her husband’s criticism and verbal attacks on her mothering abilities.

The corrosive impact of unresolved grief and loss on the couple and their family are described well, The dynamic understanding of how intrapsychic issues could be played out interpersonally within the marital relationship is reflected in the treatment approach recommended to the couple.

The clinician’s decision to put them into two different groups dealing with loss was both creative and effective. Being in separate groups, they couldn’t engage in their pattern of competing and “one-upping” each other. Also, each could be supported in their search to address their contract issues in a safe and caring environment. Once each client could process their feelings of loss, abandonment, anger, and grief, they could begin their work of emotional reengagement, connection, and trust with one another. They could begin to connect through love, not anger, and stop creating their pasts in their present. They could learn ways to support each other and maintain their home and marriage as a place where it is safe to express needs, fears, and wants and be heard and validated.

This case illustrates so well the importance of knowing our clients’ social histories. Without this knowledge, treatment is compromised. We see in this case, the role of unresolved grief and loss in both Glorya and Sid’s lives was major and the impact on their marriage and family significant. Once both could and did realize how their losses were affecting their family and their relationship, they had the courage, motivation, and commitment to make the changes internally, as well as interpersonally, so that they no longer would be prisoners of their past. They could claim their present and move forward toward their future.

— Barbara L. Holzman, LCSW, ACSW, BCD, has been in private practice in Phoenix for 30 years.