Therapy Sessions

Q: Dear Dr. Ochberg:

My name is Karen and I am a spouse of a veteran. I started an advocacy group on Facebook for people with PTSD called Click here: (PTSD) The Truth In Numbers. The Truth In Numbers is a global warehouse for the families of PTSD sufferers.

I have a question for you. Family members of PTSD sufferers try to assist their loved one by any means. For some individuals this includes attending therapy sessions designed for the sufferer. What advice would you give a family member about attending sessions meant as individual therapy for the sufferer?

A: Dear Karen:

Thank you for this question.

I ask my vet patients how they feel about having their spouse meet with me. Recently the vets have been from the current conflicts or from the Vietnam era. All have been men. Most have been married and all wanted me to meet with their wives. In about half the cases, wives joined a session so that there were three of us together in the room. In the other half, I saw the wife alone. These are billed as “collateral visits” and, usually, insurance pays. By collateral visit, I mean that the purpose is to help the veteran, but the visit is with a significant other. Sometimes that has to do with improving a wife’s understanding of PTSD (and of related issues). Sometimes it has to do with trying to help a wife improve her tolerance of withdrawn or angry behavior. In one recent case I was delighted and reassured to find that the wife really was as understanding and supportive of her veteran husband as he claimed. This veteran had homicidal fantasies, not toward his wife or co-workers, but toward those who expressed disrespect to the military mission. Needless to say, therapists (including me) worry as we work to reduce the intensity and frequency of destructive thoughts. Thanks to this veteran’s spouse, I could worry less. The fact that he, she and I could speak openly about these fantasies helped to reduce risk and to relieve stress.

So I’ll make these points as general answers to the excellent question, “What advice would you give a family member about attending sessions meant as individual therapy for the sufferer?”

First, make sure your spouse really does want you there and find out if he or she would prefer that you both go together, or that you go alone. It works best when both partners can agree on having the spouse come with or without the veteran. Either way can work well. But if the therapist insists on an arrangement that does not suit you both, I’d question the wisdom of the therapist.

Second, assume that your thoughts and feelings will get back to your spouse. Your spouse has a privileged relationship with the therapist; you do not. It doesn’t mean that therapists will repeat exactly what you say. But your important concerns and reactions will, usually, get expressed. Often, both partners end up being more direct but also more compassionate.

I’ll go on without numbering the comments:

This opportunity to meet your spouse’s therapist usually works well for all concerned. I’d have to think back a long way to come up with a family visit that disappointed any one involved.

So give the process the benefit of the doubt.

Learn all you can about the “hidden injuries” of war, and about depression, PTSD, hypervigilance, being triggered into combat mentality, having rage toward inadequate drivers.

Get a better sense, if you can, of your spouse’s pattern of PTSD (and related, lingering symptoms). The therapist may know some things that you have missed.

On the other hand, you may know a lot more than the therapist does about your spouse. Tell the therapist anything that might have been missed, and all of your concerns. For example, one spouse told me her husband was over-medicated and that is why he lost his concentration. I needed to attend carefully to this. The man had a deep depression and he did not respond to the first antidepressant. So I added an “augmenter.” And he couldn’t sleep. And he had chronic pain. And he angered easily. I found good pills for each symptom. The original symptoms improved, and he was quite enthusiastic with me. But he looked drugged at home. I had prescribed too many medications (rare for me, but it happens!)

She (the wife) was very smart, but not too sympathetic. I respected her candor and her willingness to tolerate some very difficult behavior by her veteran husband. Eventually, his symptoms and their relationship improved. It helped me to have her express herself candidly. It gave me a sense of who she was and that improved my ability to have meaningful discussions with her husband about family and household issues. So be yourself, and let it out. In the long run, this helps resolve lingering problems.

I’ve had situations where the spouse is so burdened in the caregiver role that she needed and deserved therapy for herself. In some PTSD situations, this led to joint therapy, or my seeing both partners separately, or combinations of individual and joint sessions. I avoid seeing the spouse as a patient when the partners are really adversarial. But many tense marriages have been improved when a single therapist has the chance to intervene in a constructive way.

Sometimes the patient wants the spouse involved for a while, then doesn’t. I’d say that if this occurs, consider that the therapy is reaching into some difficult areas. It does not mean that you are being neglected or disrespected. I’ve often worked with PTSD patients who benefited from having a husband or wife involved for several sessions, then really needed to tackle tough issues alone with me.

Some therapists are trained in couples therapy, sexual problem treatment, and intervention with young children. But not all are. Good therapists know their limits and refer, when asked, to colleagues or to treatment centers with the needed expertise. You should ask about these issues if they arise.

You have a right to size up the therapist and to tell your spouse what you think of his or her therapist’s abilities. Don’t consider couples therapy with a therapist that you can’t trust, just to please a spouse.

I’ve written a piece for partners of patients with PTSD:

Reading this before meeting your partner’s therapist could save time, give you a “leg up,” and help create a good sense of teamwork as you all work to overcome the hidden wounds of war.

In sum, it helps when the spouse, the therapist and the veteran are all on the same team. PTSD and TBI create difficult challenges. Mood fluctuates or is depressed. Anger rises quickly and irrationally. Self-isolation is the norm, and this makes marital life hard for the whole family. Flashbacks can be frightening, demoralizing and (rarely) dangerous. So given the chance to participate in therapy, take it. The risk is low; the benefits can be huge. They say, “It takes a village.” That village begins with you, the spouse.