The phrase "in sickness and in health" is a hallowed part of our marriage vows for good reason. As human beings vulnerable to a wide variety of diseases and infirmities, we need to know at the deepest level that our partners or spouses will stick around even when our bodies betray us, as they will eventually. And yet, even though we generally agree that abandoning an ailing partner is unacceptable, we don't really appreciate how high a toll a serious medical problem can take on a relationship. Even many couples therapists, I suspect—trained as they are to probe faulty communication patterns, sexual problems, money issues, work and family stresses—may not think of exploring a couple's medical history. But a partner's chronic illness, disability, or life-threatening medical emergency can disrupt and undermine an otherwise good relationship just as much as infidelity, addiction, or abuse. Indeed, severe medical problems can have a genuinely traumatic impact on even the strongest relationship.
Ellen and Phil looked like many other couples whose marriages aren't working—the signs were clear even in the waiting room. He was working on his PDA, and she was leafing through an old magazine with her back to him. They both had placed their coats on the seat between them. When I spoke their names, she jumped up expectantly and he finished his task before making eye contact. In the office, when I asked why they were there, Ellen said, "Phil, you talk. I'm tired of doing it all." So began what appeared to be a standard couples session in which each described disappointment and ascribed blame.
As the session proceeded, I heard the dissonances of marital problems 101: Phil was frustrated because he felt she didn't appreciate how hard he was working and how much stress he was absorbing to achieve his financial success. Ellen felt that Phil essentially dismissed her work as a school nurse and took for granted her responsibilities as manager of the home and family. They both then denied the other's accusation, insisting in turn that they did appreciate their partner. I pointed out that openly expressing appreciation can be neglected in the busy, time-pressured hubbub of a family with active children in junior high school. It was clear, as they talked, that they didn't spend much time together as a couple. Indeed, like a surprising number of couples these days, they reluctantly admitted that they'd "just ended up in separate bedrooms."
Phil smiled a bit and said that he knew I'd want to know about that arrangement. I asked whether they wanted to talk about it, and they showed a bit more comfort with each other as they quickly explained the situation. It happened for "practical reasons," they both agreed, and didn't reflect their mutual commitment or any loss of sexual interest in each other—though the arrangement did make sexual intimacy trickier to manage.
What were the "practical reasons" I asked? It turned out they'd begun sleeping in separate rooms about seven years earlier, after Phil was suddenly diagnosed with a nonmalignant brain tumor. Following the diagnosis came surgery, infection, and complications for several months, during which he was either in the hospital, in a convalescent center, or at home with nursing care requiring sterile surroundings. Practicality required that he have a separate room during his recovery.
But Phil received a clean bill of health more than five years ago, and still they hadn't moved back into the same bedroom. Somehow, this temporary arrangement had evolved into a permanent arrangement, with no discussion or formal decision. "Why?" I asked casually.
Ellen said they were both light sleepers, and it was just more comfortable this way. Phil nodded agreement. With that small matter out of the way, they were eager to return to explaining all the ways each felt misunderstood and underappreciated. But as a couples therapist who is also a medical family therapist, I told them I thought it might be useful to spend a little time talking about how Phil's illness has affected their relationship.
Stories of couples like Ellen and Phil who've experienced a significant health crisis are common in my practice. And couples who've gone through a serious medical event affecting one of the partners don't necessarily regard this as the kind of significant stressor on their relationship that could be addressed in therapy. But my experience has taught me otherwise: it's just as important to ask couples about their medical histories as about their differences concerning childrearing or views of money.
When a couple has gone through a medical trauma, both partners need to describe their unique perspectives about the illness and the meanings they ascribe to it. As with most couples issues, each sees their medical journey differently.
In talking about the illness from Phil's perspective, it was clear that he'd wanted to be as much in control of his medical situation as circumstances allowed. He readily ticked off the events of his illness, including specific dates when he first knew his symptoms were serious, as well as when he visited his family physician, the neurologist, and the surgeon. He could chronicle the details of his initial surgery and the second postinfection surgery like a medical student, and had an excellent grasp of his diagnosis, treatment, and prognosis. He described having good relationships with his physicians, and felt that he'd been well informed throughout, almost a member of the medical team.
In contrast to her husband's memories of personal agency, active involvement, and a realistically positive attitude at the time of his illness, Ellen mostly remembered her heart-clutching fear. She shuddered as she recalled the day she first learned Phil was scheduled to see a neurosurgeon, and how nervous she'd been as they waited in the doctor's reception room. She talked about the hours she'd spent each evening on the phone, updating family members and friends about Phil's condition. She tried to maintain a positive attitude, but described how, as a nurse, she'd had to fight off her nursing-school memories of people with shaved heads, loss of cognitive functioning, and terrible prognoses. She lived in constant anxiety that this might be Phil later on.
Phil listened to Ellen, took her hand, and tried to reassure her that he wasn't one of the unfortunate people. Although he agreed that there were some frightening complications, he reminded her of the success of the surgery, and that he no longer required yearly CAT scans. She looked only slightly reassured by this.
Phil and Ellen's conversations provided more than content about their experiences with the illness. The differences in their affect and the ways in which they responded to each other were informative. Through these relatively brief interactions, it appeared that Phil had a sense of competence and closure about the illness—he knew what had occurred, understood the seriousness of his illness at the time, but felt it had been well taken care of and the situation basically resolved. By contrast, Ellen, even years later, still showed physical signs of fear and agitation when she described that awful time.
As they talked about the illness, I noticed that the tone of their discussion was much different from what it'd been when they first arrived in my office. As Ellen described her distress, Phil responded with obviously heartfelt attempts to comfort and reassure her. There was a kindness and gentleness between them that hadn't been apparent when they were focusing on their grievances.
As therapists, we jump at opportunities to reinforce any glimpses of tenderness in our feuding couples. Even the most estranged couples can be brought to recognize and appreciate the support they've given and received from each other during times of family loss or illness. In fact, partners who are highly critical of each other frequently make exceptions when asked what it was like between them when a parent was seriously ill, or when a close cousin died. In times of grief and crisis, people can bury the hatchet with amazing speed, step up for each other, and be grateful for each other's support. Simply discussing these periods of illness with a couple can result in the same kind of positive feelings that emerge during recollections of their first meeting or the day they got engaged.
It hadn't occurred to Phil and Ellen that their trauma several years ago could have much to do with their present troubles, so I used a metaphor that I use often: a serious illness like Phil's tumor and surgery resembles a large tree falling on the house. It suddenly comes crashing down as if from nowhere, does a lot of damage, and leaves lots of debris requiring repair and cleaning up. It can be very dangerous, even fatal. Though it may be tempting to try to assign blame for the falling tree or obsess about ways it could have been avoided, most agree that this is just an unfortunate, random event, which nobody can predict or prevent. Afterward, however, we continue to relive the event, and may even become much warier when walking near trees. The point of this trivial example is to help people realize that illness is a real, often deeply frightening, event, with an impact that can long outlast its actual duration—years after the tree has been sawn up and carted away and the roof repaired, we may still remember that first terrifying crash and can't help but wonder when the next mighty oak may fall our way.
When Phil did acknowledge some residual fear, it was reassuring for Ellen. She noted that it appeared to acknowledge his frailty, which she'd feared earlier that he hadn't recognized. They later seemed to find it helpful when I explained how ambivalence about an illness is often expressed by a couple. For instance, one will take the role of the worrier while the other voices certainty of good health. It's a way of "sharing" their ambivalence, but it can lead to polarization when each adheres to one position on the continuum between severe worry and complete confidence. Phil's statement that he doesn't dwell on fear allowed Ellen to see that although he didn't discuss it, he also experienced some uncertainty. It was freeing for her to realize that she didn't have to hold all of the uncertainty for the two of them.
As we discussed their coping styles, Ellen and Phil both noted that, by common consent, Ellen's fears hadn't been a topic of conversation between them. As Ellen and Phil grew more comfortable with the notion that it was fine that they had different responses to Phil's illness, they took more risks with each other to open the discussion further. We explored the common patterns that evolve when one partner becomes the other's caretaker.
Ellen and Phil were relieved to consider that their sexual avoidance wasn't a statement about their poor marital functioning, but an unwelcome intruder that often visits couples experiencing illness. It helped them stop blaming themselves and each other, and provided hope that they could return to a "normal marriage."
In therapy, Ellen and Phil have come to understand that the crisis had shaped their relationship much more than they'd been aware of. This meant that, rather than blaming each other, they could come together in recognition of the common sadness and pain they'd both endured. They could externalize the cause of their problems as the illness, which had literally been an intruder in their lives, making it immeasurably more difficult to withstand the normal disappointments and frustrations of daily existence.
This blog is excerpted from "When Illness Moves In" by Jeri Hepworth. The full version is available in the May/June 2007 issue, Say Ahhhh...: Collaborative Health Care Just May Change the Way You Practice Therapy.
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