During the separation, Carol had a number of individual sessions. Historically, her upbringing emphasized good work habits and diligence. Her father had been a worrier. Like her father, she was rational and emphasized facts rather than elaborations of meaning or abstractions. As a protection against her father's sometimes intense anger, Carol had simply avoided him with hard work and projects. Carol stated that the citalopram(Drug information on citalopram) made it easier to control her defensiveness; reduce her extensive strategizing for saving the marriage; and enhance her connection with her family, colleagues and friends. The medication helped her ignore her almost constant rumination about John. In addition, she could fall asleep more easily.
John and Carol decided to continue their marriage. John has begun to understand that his demands on Carol reflected his unmet lifelong need for greater affection. Carol and John have gradually reversed roles, with John becoming more assertive and less needy and Carol accepting more dependency and closeness. They are beginning to discuss what their life will be like after Daniel leaves for college.Discussion
Therapy with John and Carol moved through the four stages mentioned at the beginning of this article. In the initial stage of therapy, John's complaints were addressed in a concrete way, helping him feel that the therapist took his concerns seriously. In the second stage, in accord with the work of Johnson (2001), the "attachment disruptions" were clarified. That is, John felt betrayed by Carol's lack of attentiveness, while Carol felt betrayed by John's desire to break the marriage contract and his inattention to her needs. With time, however, John and Carol developed greater trust and better communication of their needs, permitting a historical and developmental exploration in the third stage of therapy. At this point, in the third stage, medication supported John and Carol by increasing the flexibility of their personalities. Finally, in the fourth stage, John and Carol were able to consider mid-life issues and the challenge of living life to its fullest, as Daniel approached emancipation. Hopefully, during this transition, John and Carol will also be able to accept the limitations of their upbringings and the sacrifices of parenting.
Although medications were used in this case primarily to address stage-3 personality issues, psychopharmacology can effectively complement therapy at any stage. For John and Carol, psychopharmacology also reinforced the initial stage-1 behavioral changes and the stage-2 corrections of their polarized power balance and intimacy styles.
Therapy with Carol and John highlighted the issues of boundary and power dynamics. Therapy included a discussion of complementary styles and temperaments. In this couple, traditional gender personality styles were reversed. Generally speaking, additional tension occurs in couples where the woman is more directive and distant than the man. With Carol and John, medication helped balance gender style polarities and reduce tension without making Carol overly submissive. Both pharmacotherapy and psychotherapy were intended to help John and Carol move toward the middle ground of their interpersonal and internal personality polarities. That is, John would gain a broader perspective on his feelings and take charge of his own needs; conversely, Carol would be able to tolerate some dependency and give up some control.
Using the ideas of Cloninger (1997), the clinician can more fully integrate biological temperament issues and learned character qualities. In biological temperament, John was especially sensitive to outside rewards and approval. Carol was excessively persistent in problem-solving. In learned character, both Carol and John had difficulty with interpersonal reciprocity.
Although not yet fully supported by research, I believe sorting out biological from learned factors in personality style will help form the basis for using medications to enhance personality flexibility. New research on biological aspects of attachment continues to evolve. For example, Young et al. (2001) have described oxytocin(Drug information on oxytocin) and pitocin as neurotransmitters that enhance attachment behaviors in animals.
My personal and professional biases toward preserving families and the need for at least exploring marital dynamics before divorce were openly shared with John and Carol. In this therapy, I could feel the pull of emphasizing practical problem-solving with Carol and the pull of caring for John. The main transference and counter-transference, however, was directed back to the couple and their interaction. With Carol and John, I felt comfortable as a psychopharmacologist, problem-solver and personality therapist. I felt I had relearned lessons about obsessive versus narcissistic style polarities, accepting limitations in life and balancing inner needs with outer responsibilities.Conclusion