Clinicians Digest Nov/Dec 2008

Infidelity and Disclosure

By Garry Cooper

Louisa confides to her couples therapist that she had an extramarital affair last year and asks him not to divulge this to her husband Frank. Although therapy has been progressing, Louisa's revelation troubles her therapist. Does Frank have a right to know? By not disclosing, is the therapist participating in secret-keeping and aligning himself with Louisa against Frank? Writing in the July American Journal of Family Therapy, a group of Brigham Young University researchers say that surveys of marriage and family therapists indicate that up to 96 percent of therapists would comply with the request of an unfaithful spouse.

The trio, Mark Butler, James Harper, and Ryan Seedall, suspects that most of those therapists were thinking more about the ethics of confidentiality than the principles of effective therapy. They argue, however, that if they were more concerned with good couples therapy, they'd focus instead on moving the unfaithful partner toward disclosure.

Butler, Harper, and Seedall's viewpoint mirrors the attachment perspectives of therapists like John Bowlby and Susan Johnson, who hold that affairs are corrosive, even antithetical, to intimacy. From this perspective, they insist, there's no such thing as a harmless affair. The Brigham Young trio also argues from the ethical position that each person in an intimate relationship has the right to choose the relationship's boundaries and limits, and that such choices depend upon knowing all relevant information.

They do, however, acknowledge some circumstances in which disclosing an affair might cause more harm than good. "When the affair's in the distant past," says Butler, "or one partner is terminally ill or disabled, the therapist might reasonably wrestle with a cost/benefit analysis." Similarly, if disclosure might trigger domestic violence, or one or both partners have severe psychopathology, disclosure may be too hot to handle. And when divorce is imminent, disclosure is likely to become only a punitive tool or legal fodder.

But the relationship between values, social science, and theoretical orientations is seldom as clearly delineated or cut-and-dried as we'd like. Couples therapist Esther Perel, author of Mating in Captivity, contends that views like those of Butler, Harper and Seedall are more value-laden than scientific and may create more harm than good. The role of a therapist, she insists, "isn't to advocate for disclosure." Instead, she says, therapists should help people examine why they had the affair and whether they should disclose it, and to own their choices about the affair and disclosure. She points out that the meanings of fidelity, love, and intimacy vary widely, and rather than impose their own values, therapists should help couples explore what these concepts mean to each of them.

So what should a therapist do when one person privately admits an affair? Butler, Harper, Seedall, and Perel do agree on one point: above all, therapists need to be clear with themselves about their personal values and theoretical orientations to be able to separate their own attitudes from what's best for their clients.

Deep Brain Stimulation for Depression

Despite the millions of dollars spent on research and clinical trials of promising new treatments for depression, about 10 to 20 percent of clinically depressed people suffer from treatment-resistant symptoms that no antidepressant or psychotherapy seem to alleviate. Their only option then is electro-convulsive therapy (ECT), which has devastating, albeit usually short-term, side effects on memory and affect. Sometimes even ECT fails to alleviate their depression, and when it does work, its effects can be short-lived, with the "cure" turning out to be a few years' respite before the next round of ECT.

For years, researchers have been testing three high-tech neuromodulation solutions for depression: vagus nerve stimulation, repetitive transcranial magnetic stimulation, and deep brain stimulation (see Clinician's Digest, November/December 2000, November/ December 2004, and July/August 2005). The FDA has already approved vagus nerve stimulation (VNS), in which electrodes and a pacemaker-like device are implanted in the upper chest to stimulate a nerve that runs from the brain stem to the abdomen. In repetitive transcranial magnetic stimulation (rTMS), painless electromagnetic impulses are delivered to the outside of the skull.

But a review of these treatments in the June 2008 Mt. Sinai Journal of Medicine points out that clinical trials of VNS have yielded such modest results that the FDA approval seems based more on the safety of the VNS procedure than its efficacy. As for rTMS, the review concludes that the mild improvements it causes don't seem to last. However, the results for the third treatment, deep brain stimulation (DBS), in which surgeons implant electrodes into the brain's cingulate gyrus and wire them to a small generator implanted near the collarbone, are "highly encouraging."

In the most recently published DBS study, in the September journal Biological Psychiatry, six months after the operation, 12 of 20 patients showed significant clinical progress, with 7 of the 20 improving so much they were deemed in full remission. Moreover, the positive effects lasted a year, the longest anyone has tracked DBS. Those results are even more impressive when you consider that these patients had failed to respond to a minimum of four other treatments, including ECT.

DBS has some drawbacks. It entails brain surgery, with the usual surgical risks—primarily infections on the skull—and is extremely costly. But it's already being used to treat Parkinson's Disease successfully, and it creates no memory loss. Moreover, patients undergoing DBS report that the minute the pulse generator begins, they feel as if a switch has turned off their depression.

A large clinical trial is now recruiting subjects in Chicago, Dallas, and New York City. Advanced Neuromodulation Systems, the manufacturer of the electronic device, believes this will be the final step in gaining FDA approval. If that happens, DBS is likely to become an important new treatment option. (Recruitment details of the trial are at www.BROADENstudy.com. )

PTSD Treatments and the Dodo Bird

Researchers keep hoping that head-to-head clinical trials of treatments will tell us which treatment is the best for each specific disorder. Yet way back in 1936, psychologist Saul Rosenzweig observed that head-to-head trials of responsible treatments will typically show that they all have roughly equal effects. This is Rosenzweig's so-called Dodo Bird Verdict, named after the character in Alice in Wonderland, who judged a race by declaring, "Everybody has won, so all shall have prizes."

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