Marital partners often have complementary but conflicting personality styles. Carol was a perfectionist and worked long hours. She was perceived as kind, caring and giving, even though she was not very expressive. John, in contrast, was more laid back, expressive and needy. He craved companionship, romance and family outings. The marital personality polarities included his feeling versus Carol's thinking.
Diagnostically, John had narcissistic (insecure) personality traits. This categorical diagnosis was considered in addition to a dimensional diagnosis of mild depression along the reward/approval seeking, depressive temperament spectrum. Carol was diagnosed with obsessive-compulsive personality traits (with a controlling personality style). In addition, she was diagnosed as mildly anxious along the persistent, anxious temperament, obsessive-compulsive disorder (OCD) spectrum.
Initially, the process of therapy helped Carol respond to John's wishes. John's threat to leave the marriage seemed to capture Carol's attention. She cut back her working hours and began to seek pleasure for herself and with John. She was taught to restate and understand John's wants and needs. These changes helped Carol's flexibility as an individual and helped John as well. Carol demonstrated a lessened concern for appearances, became more available to her friends and family, and developed more empathy.
John's lack of attention to Carol's feelings of hurt, aloneness and betrayal was identified, but corrective work on this lack of reciprocity was delayed until later. After six months of weekly therapy, with Carol changing and being more available, John was more aware of his responsibility for problems in the marriage. He became more depressed and reflected about other relationships where he expected too much.
At this point in the therapy, I introduced medication for John, explaining that it would help relieve his suffering. This presentation resonated with his basic sensitivity to feelings and emotional life. Bupropion (Wellbutrin SR) 200 mg daily helped John tolerate his sadness and begin to think about his childhood experiences. I selected this noradrenergic/dopaminergic enhancer knowing that sexual side effects, especially important to John, would be minimal. I speculated that these reward-system neurotransmitters would match John's reward-seeking style. Also, John's depression was characterized by sadness and lethargy without the complications of impulsivity, agitation or loss of day-to-day functioning. A few weeks later, as the marriage crisis became more acute, Carol started citalopram(Drug information on citalopram) (Celexa), 20 mg/day. To match Carol's rational approach to life and her need to be in control, I presented this medication as an adjunct to control her anxieties, worries and obsessive-compulsive tendencies. I selected this particular serotonin-enhancing medication knowing that its sedative properties would be especially helpful with Carol's agitation and sleep difficulties.
John felt that the buproprion made it possible for him to face memories that were too difficult to confront in previous therapy. Historically, John's father was foreground in his concerns. The father, an alcoholic, alternated between expressing love and hate. John's memories resonated with his son's current developmental issues. John's mother was generally distant and passive, and John was concerned that he also was too passive. Individual sessions with John focused on "divorcing" his father--that is, leading his own life without being preoccupied with the father's alcoholism, love or lack of love. It became clearer that John wanted Carol to be the parent he never had, to be competent, as well as adoringly and lovingly submissive.
After eight months of therapy, John decided to move out. He then revealed that he had an outside romantic relationship with his secretary. John's secrecy complicated both the trust within the marriage and the progress of therapy. John thought he was behaving like his mother, who lacked directness and honesty; I pointed out the similarity to his father's deceptions. John began to understand the emotional meaning of the affair and missed his son. He decided to put his outside relationship on hold and move back into the home. John compassionately told his secretary that although he loved her, he felt a moral and ethical obligation to preserve his family.
John agreed that his return home would be more like a roommate relationship until a new contract could be worked out in the marriage and the decision regarding divorce was resolved. Both John and Carol stated that their goal was a truly intimate relationship.