It came, with a vengeance, as the honeymoon wound down. Molly had struggled with bipolar disorder since her early teens. Now, as she left her parents' house for the first time to build a new life with her husband, a fierce depression settled in.
"My aunt died just before her granddaughter was born, and I remember saying that I was the one who should have died," Molly says.
The first year of their marriage was a maelstrom of agitated, angry mania, depression, withdrawal from the relationship, and suicide attempts that occurred with increasing and alarming frequency. "It came to a point when I was in the emergency room almost every week," Molly says. "I was cutting myself, taking too many pills…" At one point, she went home to her mother – the only person who had ever seen her in such straits before.
Molly and Stefan had only known each other for four years, and had been married for a painfully short time. On their first wedding anniversary, Molly found herself in Butler Hospital's inpatient unit after another suicide attempt.
"He never left me. He didn't give up on me. I didn't want anybody else, any other family involvement. I just wanted him. And he never left me."
Still, there were challenges. Stefan, himself a survivor of an abusive first marriage with a history of depression, was overwhelmed by Molly's anger and his own powerlessness in the face of her illness.
"I came home one night and she told me to leave," he says. "I hadn't been that depressed in a long time. And I was worn out from going to the ER [with Molly.] It didn't seem normal to go that often."
"I don't like anger and yelling and swearing," he says.
He would get into his black Jeep Liberty and drive, just drive, trying to clear his mind.
The relationship began to crack, irreparably it seemed, upon Molly's admission to Butler. She had pushed him away, he had withdrawn, and she thought he didn't care. Divorce was actively considered.
Dr. Heru suggested family therapy, and they eagerly accepted – despite some misgivings on Molly's part. "I said but what if we can't take it and have to say forget it," she says. "He said if you don't want it to get better, it won't."
Their contract offered a road map to healing. Tell him your needs. Express your feelings to her. Learn to read the signals of her illness. Work with psychiatrist to minimize fatigue. Find mutually satisfying interests. Take a long drive – a special challenge to Molly in her manic state. Work together to identify and solve emotional problems, should any arise in the future.
The journey is far from over. It is a long road, but they are on it together.
"He is my heaven," says Molly. "He hardly ever raises his voice to me. He treats me like gold. He is the nicest person I know."
Untangling complex relationships
Molly and Stefan's commitment to family therapy is a critical factor in their success to date, says Alison Heru, MD. "Right from the beginning, they were motivated to work," says Dr. Heru. "They showed up, never missed an appointment, and worked hard."
"This couple was especially vulnerable, as it was so early in their marriage, and her personality was interacting with her illness to make it even more difficult for them," says Dr. Heru. "The value of family therapy is to pull all that apart and help people see the various components of their relationships. Things get so tangled up for people that they can't analyze the situation objectively."
At Butler, family therapy begins with a family meeting and a comprehensive assessment, which yields a list of specific problems to be addressed in therapy. These issues are encapsulated in a problem statement that appears at the top of the family "contract."
"On the [inpatient] unit, what I always strive for is to have the family involved in treatment, so that I can help patients and families understand psychiatric illness in a family context," says Heru. "A significant body of research has shown a high correlation between depression and poor family functioning. Families that are doing most poorly in terms of communication and other key factors tend to have the highest amount of depression, and often have a high level of reported depressive symptoms in the caregiver of the family member who has actually been diagnosed."
"There is also significant evidence that involving family members in our treatment plan reduces frequency of relapse and ultimately cuts the cost of patient care," she adds.
Ivan Miller, PhD, a Butler-based researcher, concurs. "There is more and more evidence that depression is not an episodic illness, but a chronic one … with symptoms that continue between acute episodes. Living with and adapting to somebody who has some symptoms can be quite a stress. Families are dealing with disruption in role function, adjusting to the fact that the affected family member can't contribute as much to the family system … there are many factors, and research has shown that there is significant impairment of family functioning even six and 12 months after acute illness."
"Families need to be involved in the treatment of depressed patients," says Miller. "The greater the involvement of the family, the higher the likelihood that depressed patients will have a positive outcome."
Butler Hospital a leader in family therapy
The site of the internationally renowned McMaster Model of Family Functioning, Butler Hospital – a teaching hospital affiliated with Brown Medical School – is one of a handful of institutions across the U.S. that train physicians in family therapy. It is a mission that the hospital takes seriously, and one that will affect the availability of this effective treatment for a generation to come.
"Current [insurance] limits on the number of [psychotherapy] sessions makes it challenging to do family therapy," says Miller. "But an even bigger challenge is the number of qualified family therapists across the board. These therapeutic skills are difficult to learn, and require an intensive educational commitment."