Moments of Revelation

October 1, 2007
Jerry M. Lewis, MD

Psychiatric Times, Psychiatric Times Vol 24 No 12, Volume 24, Issue 12

There are moments in therapy that seem to have a special, illuminative quality; something important is suddenly revealed. Such moments may come as the result of deliberate observational and interventional processes or may emerge from the therapist's unconscious.

The couple came at the advice of their rabbi and as part of a series of premarital procedures. They were both in their 50s and shared histories of dysfunctional childhood families and adult relationship failures. Each was a successful professional-she a doctoral-level teacher at a local community college and he a pathologist at a nearby teaching hospital. They had been together for 3 years, the last of which involved living together. He seemed deliberate and cautious; she was full of affect. At about the midpoint of an initial 90-minute interview, he described his only sibling, a younger brother, as a successful businessman. She responded by softly disagreeing with him.

"Jim," she said, "your brother has had real difficulties holding on to jobs for more than a year or so."

He was silent for a few moments and then (with much emphasis) said, "He is a successful businessman."

She looked away, the animation drawn from her face. A tense silence grew until he went on to describe other aspects of his family experiences. After several minutes, I asked whether either was aware of what had happened between them a few moments ago. They were both silent, she with what I thought was a sad expression and he looking perplexed. I said, "Here's what I observed. Jim, you were describing your brother as successful. Jane, you disagreed, pointing out his difficulty in sticking with a job. Jim you repeated-with great emphasis-that your brother was successful. Then, Jane, you looked away, and I thought your face looked sad."

They were silent for a moment, and then Jane began to softly cry. "This is really a big issue for me. All my life I've struggled not to be dominated-to have my own voice, and as much as I love Jim, there are these moments when I feel totally unheard. It's as if I don't exist."

"And yet," I responded, "you said nothing-just turned away, sadly, I think."

"I'm too afraid," she said. "I'm afraid I'll lose him if I disagree too often with him."

"Jim," I said, "are you aware of how absolute you can be, and what that does to Jane? She feels that she doesn't exist at that moment and then is too afraid to let you know how she feels."

"I am not aware of coming across in such absolute terms, but know it would bother me if someone very important to me talked that way to me. It's something I need to do something about," he responded.

We went on to discuss this central relationship dynamic and possible ways of dealing with it. They agreed that he was drawn to her affectivity and she to his solid, down-to-earth quality and that unless she could become more comfortably outspoken and he more aware of his relational impact, trouble might be in their future.

The major point of this essay, however, is the illuminative quality of their brief interaction. It is as if they jointly opened a window on an important dimension of their relationship structure. This allowed me to explore the interaction with them, and the result was the beginning of new learning about dealing with differences, respect for each other's subjective reality, and the relational language of negotiation. This was made possible not by any special skill on my part but by following the rule (in dealing with couples or families) that the clinician's conscious focus should be more on patterns of interaction than on individual characteristics.

The second experience occurred with an older man who had flown in from a distant city for an afternoon consultation. His wife accompanied him, and although I spent some time with her and some time with them together, the bulk of my time was with him alone.

His story involved having accidentally run into his college sweetheart of many years ago. His wife was out of town at the time, and he felt increasingly preoccupied, perhaps obsessed, with this woman from his youth. They began to exchange messages and then arranged a several-day visit together. Although nothing in a physical sense happened, his time with this woman came to have a special aura. He was excited and began to feel that his earlier love for her had been rekindled and that he needed to spend a period of weeks, even several months with her to evaluate what to do. The problem, of course, was that this was unacceptable to his wife-doing so meant the end of their marriage.

The context of this clinical situation included the following. His present marriage was of 25 years' duration and was described as a major and positive turning point in his life. His past history included childhood neglect by his prominent parents and early adult relationship failures. It was this marriage that had been experienced as healing. Further, his wife's trip out of town (a fun trip with close women friends) had occurred right at the time of his 80th birthday. He denied anger about this, saying it had been planned for a long time.

His wife, in turn, reported that in the several months before his birthday, he had become increasingly irritable, was experiencing early morning awakening, and had been drinking more than usual.

As I was sorting out an initial formulation of his and their dilemma to offer some recommendations, my mind turned to the role of his repressed anger about her trip, his possible narcissistic issues (ie, the usual rules did not apply-"I should have my experience with my college girlfriend and continue my marriage"), and other psychodynamic themes. In the midst of all this clinical thinking, a recent conversation with my wife came to mind. I told my wife (on the occasion of my 82nd birthday) that I hoped the next major event in my life would be my death. Somewhat familiar with such provocations, she asked me to explain. I told her that other major events-her death or that of one of our children or grandchildren-would be catastrophic for me, and with my career in its final stages, death as the next major life event seemed reasonable, even desirable. We talked further about this, and she seemed reassured that the idea made some sense and that I was not depressed.

The intrusion of this personal conversation into my mind while with the patient seemed at once of obvious importance in my efforts to understand the patient. At the time of his 80th birthday, his wife went on a fun trip and he became preoccupied with reestablishing a youthful romantic relationship. Life is not nearly over; death is not the next major event; there is no need for depression-indeed, start anew. The problem, however, was that he could not pull it off. He could not risk losing his wife nor would his old girlfriend erase the inevitability of what was to come. Perched on the edge of existential despair, he searched for a solution that would not come.

These two examples-so different in their essential processes-are the types of experiences that make the work of psychotherapists so utterly fascinating.