Scenario

“Please come in, Dr. and Dr. Galvin. Please take the chairs over near the fireplace so we can all be comfortable and talk.”

The tall, gray-haired man escorting the two doctors into his office was dressed very casually in his plaid shirt and well-worn khaki pants. He looked compassionately toward the obviously anxious couple as they took their places, and he sat down opposite them.

Marty Canter watched his new patients explore his room with their eyes, trying to pick up clues as to what sort of person he might be. He was unconcerned. His room was comfortable but simply furnished, with one waist-high plant by the single large window and the usual framed degrees validating his profession scattered across the walls. He, and it, had survived the inquisitive looks of many couples over the years without giving too much away. He had an old desk set in the corner of the room; his laptop sat atop it. Heavy velvet curtains hung beside the window, ready to block out the excess summer sun that frequently flooded the room. The main focus was the seating area, the three deep lounge chairs placed around a large fireplace that, although used only occasionally in winter, dominated the room. One wall included a collection of photographs of places across the country where Marty had worked during his long career as a family therapist—no family photos, just buildings. Sometimes his patients asked about the photos, especially the one showing a large, rather forbidding structure that, before it had been demolished, was the psychiatric hospital where he had done his internship many years ago. His first impression of this powerful-looking couple, who seemed very disconnected from each other, was that their focus and interest would be more on themselves, and less on him.

Marty remembered the referral he’d received from his friend of many years, Dr. Jordan Vine, a psychiatrist he had first met during his internship through their mutual love of baseball. Now, they frequently referred patients to each other and often combined their psychiatric and therapy skills, working together to better help their patients. In this instance, he had been at Jordan’s home for dinner 2 weeks earlier, and toward the end of the evening Jordan had taken him aside to ask him to see the Galvins, a well-known physician power couple in the city who frequently graced the social pages. Jordan told him that he had been treating Cathy Galvin, a vascular surgeon, for severe depression and that, although she was no longer actively suicidal, during her therapy it had become obvious to him that the couple had some major relationship problems. Jordan had seen Cathy’s husband, Brett, a family physician and chair of the local medical society, a couple of times in sessions with Cathy and had discussed marital therapy with them. They had both acknowledged longstanding relationship difficulties and agreed therapy was worth trying, hence his referral to Marty Canter. As they went back to the dinner party group, Jordan added that he was not at all sure that their marriage was salvageable; he wished he could engage Brett in treatment also but the suggestion had been met with a blank refusal and an annoyed, dismissive response that he did not need to see a psychiatrist.

Marty sank into his burgundy leather chair, making himself comfortable, pen and pad in hand for his notes. Cathy Galvin opened the conversation.

“Thank you for seeing us. We understand you’re a friend and colleague of Dr. Vine, who speaks highly of you. We’re both a bit concerned, though, because you’re not a psychiatrist or a psychologist, who mostly have Ph.Ds. We just want to be sure that you understand the special needs that doctors have and the difficult lifestyle and pressures that affect us. Just as patients often ask me how many patients I’ve operated on for their own problem, I would like to know if you have seen many doctors for therapy?”

Many inexperienced therapists would have been threatened by Cathy’s direct and somewhat intimidating approach. Marty just smiled inwardly. He had heard this style of attack many times previously and understood that what could be perceived as arrogance actually often arose from anxiety and Cathy’s underlying fear that he would be unable to help them. She had to check him out to reassure herself.

Marty looked carefully at the Galvins. They were both in their early fifties. Cathy had a striking face, long and thin, with dark rings under her large brown eyes that were partially covered by makeup. She had unusually smooth facial skin, possibly from a successful recent facelift, he suspected. Her long, black hair was tied back in a tight ponytail, and she wore a dark, conservative business suit, black pumps, and a single-strand gold necklace. She appeared to be a powerful woman who could have come from any high-level professional occupation, law, engineering, business, or medicine. She sat apart from Brett, her knees and elbows pointing away from him, her body language building an unseen wall. Very intense.

Brett, on the other hand, struck Marty as being much less commanding than his wife. He looked tired and rather beaten down, a bit like a faithful spaniel who has lost his way but is trying to keep up with his master. He seemed less certain of himself and made little eye contact. He looked his age, with blotchy skin and his share of wrinkles, but his long, carefully styled white hair suggested that a hair dryer might be in regular use. Like his wife, he wore a perfectly tailored suit and polished black leather shoes, all finished off with a Rolex watch that gleamed on his left wrist.

They were an interesting couple. He sensed that they both would rather be anywhere but in his office today. Marty wondered about the details of their journey together and whether they could be helped. He decided to reassure Cathy first and then start exploring why they were consulting him.

“I understand your concern, Cathy, because you’re right, it is important to understand the culture of medicine, the realities of the world you live in and the pressures on you both as a result. Because I am a marital therapist who regularly sees physicians, I have a good understanding of the other extra pressures that occur within any marriage of two physicians, especially the juggling of competing careers and schedules and how these may intrude on family and home life. I understand that you both work in very different areas of medicine, surgery and family medicine, and I would guess that those issues have been important to you both over the years. Is that the case?”

“They certainly have been,” said Brett, “but I think we’ve managed to overcome a lot of those difficulties. Certainly, my career in family medicine has helped because I’ve been able to be more flexible than Cathy. The surgical training, especially for a female, is simply murderous. We decided not to have children, for instance, until Cathy had finished her residency because of her long, unpredictable hours and because the hospital where she was training didn’t have good childcare facilities. It would have been almost impossible for us to manage children at that time of our careers with our shift work.”

“I’ve heard a lot of doctors complain about the difficulties of bringing up children with the required schedules,” said Marty sympathetically. “How many children do you have, and how old are they?”

“Two. James is 12, and Sashi is 10,” said Cathy. “We were actually very fortunate to have them because I was a relatively mature mother at the time, after finishing my fellowship in vascular surgery. Fortunately, they’re both fit and well, although we did have a very hard time with James, who was mistakenly diagnosed with microcephaly—a very small skull—when I was pregnant. I think that was the first time we really had major problems in our marriage. I’ll never forget being alone while having the ultrasound that led to the mistaken diagnosis. I had to discuss the possibility of a termination without Brett there because he was stuck in clinic with an acutely ill patient he couldn’t leave. I think I blamed him for that for months, even after James had been born completely healthy. I was just so used to attending all my OBGYN¹ appointments by myself. Suddenly I realized most of the other prospective mothers had their partners with them for at least some of the visits. I know it’s the life we signed up for, but it’s been tough at times. It may sound odd, but sometimes we’re lonely because we’re both doctors and have commitments that pull us apart. We have so often had to be that way—just one parent available for our children at a schoolteachers night, sports day, or the first day of school. We’ve become excellent schedule jugglers, but only so that one of us can get to these events. Sadly, for me and for the children, Brett usually has been the parent present. He’s been really good about that, but it hit home to me when one of the parents in James’s class asked Brett if he was a single parent. I wish I could have been there for the children more.”

Cathy sat back, suddenly overcome with emotion. She felt like crying but forced herself to maintain control and not show her reactions too openly. This was something she had learned over many years in surgery: to keep herself emotionally distant from the many awful traumas she experienced so she could better support and advise her patients. She was surprised at herself for being so open with this stranger about one of her greatest disappointments in life—being more absent than she would have liked in the lives of her children. It felt odd.

“That sounds rotten, Cathy. I appreciate how difficult that must have been for you,” Marty responded. “However, I imagine that this must have been only one of a number of difficulties you’ve both had, or you wouldn’t be here. Could one of you tell me a bit more, so I have a fuller picture? And please remember that, as a marital therapist, I won’t be taking sides in any of this. It’s my job to work with you both to try to resolve any problems that you wish to discuss. Of course, some issues between you may arise that you don’t want to include in our discussions, and I will certainly respect those boundaries.”

Brett decided it was time to give his perspective. Lifting his head and taking a deep breath, he jumped into the conversation.

“Cathy and I have been married since medical school. We met early in our first year and rapidly became inseparable. In my view, Cathy is more intelligent and ambitious, and I think if you can get her to be honest, she will agree on that. She always wanted to be a surgeon. Even in medical school, she was determined to be the star student. She was on the dean’s honors list and has always worked incredibly hard, so it was no surprise when she got into a prestigious surgical training program. Fortunately, I was able to follow her and obtained a residency in family medicine on a partners program. In some respects, I’ve always felt like the person who has to pick up the pieces behind Cathy as she becomes more and more highly trained and successful. We had large debts from medical school, about $400,000 between us, and they really overshadowed our first 5 years after residency when we were both working extra-long hours to pay them off. At the same time, we were trying to start a family, which took several years. I’ve always thought we were just too stressed for conception to be successful quickly.”

“That, combined with my night work schedule, meant we were only together a few nights a week, and I was always exhausted,” said Cathy. “So don’t just blame stress. If you remember, we weren’t actually having sex that often either, then or since, so it’s not surprising it took a while for me to become pregnant.”

“Please, Cathy. I don’t think we need to get into that level of detail here!” said Brett, rapidly and in an irritated voice. “It’s the problems we’ve been having over the past 5 years that are really why we’re here, as we both discussed. Or do you want to cover different areas? I, for one, do not want to go back over ancient history. It cannot be relevant now.”

Brett looked angry and suddenly more assertive, emerging from his initially dependent, passive role and glaring at his wife before turning away from her to look directly at Marty. Surprised at how quickly the temperature between the couple had increased, Marty decided to intervene. He sensed an escalating dispute occurring as Cathy drew farther away from Brett and showed her own anger in her body language.

“I’m sure we’ll have time at some stage to go over numerous issues. Sexual problems certainly are common in most relationships that are having difficulties and can be either a symptom or a cause. Let’s go back to why you both think you’re here. Perhaps it would be best if you could individually talk about that directly to each other, letting me be the observer. That way, we can clear the air and identify more precisely what you both feel and think and where we should start working. Who would like to go first?”

“Okay,” said Cathy. “I’ve already been branded as the ambitious workaholic in our marriage, so I’ll take the first shot at this.” She turned to Brett, moving her whole body around, crossed her legs in a business-like way, and looked him directly in the eyes. “Brett, one thing that frustrates me is that you’re always trying to please everyone, and putting me last, because you’re so used to me being able to cope. You’re a great family doctor; you go out of your way to help all of your patients. Nothing is too much for you. You are the same with our children; you seem to love the fact that their teachers automatically go to you first for any parenting questions. And you’re proud of being what others think of as a ‘hero’ because you cover for me so much of the time and are the perfect dad. So they all admire you and think I’m not being a good mom. That’s how the public sees you.”

She paused, seemingly to take a short break, but Marty wondered if her pause was also for effect. When she continued, she spoke carefully and in a way that seemed almost rehearsed. If not rehearsed, then it certainly was well thought through and calculated.

“Brett, your private face is different from your public persona. You’re not nearly as good at coping as others think. I see all the hours of work you do at home to make sure your medical records are up to date. I know how difficult it’s been for you to adapt to the EMR,² but how you won’t admit it and get extra help or coaching. Instead, you spend half your weekends trapped on the EMR, communicating with your patients by messaging. Of course they all think you’re wonderful if you respond to them at 10 P.M. on a Sunday. I see you looking exhausted, and lately I’ve noticed you’re drinking too much, almost always polishing off a bottle of wine every evening. You never used to do that. I’ve talked to you about your drinking many times, and you won’t acknowledge it or even go and see a colleague to be checked out. Why, you don’t even have a family physician yourself, although you tell all your patients to make sure they always have regular checkups with you! We both know you have some erectile dysfunction, perhaps caused by your drinking, and as a result you avoid intimacy with me. Maybe your charting at home is just a convenient excuse to avoid spending time with me. So, my main point is that I want you to start looking after yourself better. And I want to be looked after as well, and not used as a reason for you to look good to others. I’m sick of you working on the EMR at home and wish you could finish your work at work, so you can be a dad and a husband at home. I know I’m not perfect, and I’m sure you’ll talk about that, but I really do want us to succeed and stay together. It’s as though we’ve become more like roommates than a couple, and that has to change. That is what I want from coming here, to try to get us back on track. That’s why Dr. Vine sent us here.”

“I know why we’re here, Cathy. You don’t need to remind me,” Brett replied tersely. “You seem to have Dr. Vine on a pedestal. We have to do exactly what he suggests, because he can’t be wrong. I know you think he’s perfect in comparison with me. I can’t believe you’ve needed all those appointments with him to just talk about yourself. I see how you always dress up to go and see him. Do you know that sometimes hearing you describe him is like listening to an adolescent girl with a crush? All I can say is that I know you think I’m overly suspicious of you, but that’s hardly surprising, considering you have admitted to having at least one affair in the past. I’ve asked you a dozen times to see a different psychiatrist, and you always refuse on the grounds that he saved your life when you were seriously suicidal. I think you have a thing for him, and he comes between us. I don’t want to feel like I’m in second place.”

“You’re being unfair, Brett. I thought we’d worked through that one time I messed up. It didn’t mean anything, and you know it. I was drunk, and it was one night. I think you’ve beaten me up enough on that one. It was 5 years ago! This is complete nonsense. How often do I have to tell you? Dr. Vine is my psychiatrist, and that’s all. I know you’re worried that I will repeat the past. Can’t you ever get over that one mistake of mine? You told me you were over it, and now you throw it at me again. I was desperate at the time and have promised it would never happen again. I have felt awful and so guilty about what I did that night. But here you are, within a few minutes of meeting a therapist who’s meant to help us, bringing up old ground once again. You know exactly what happened, and I promise all that is in the past. We need to concentrate on now. And I am going to continue seeing Dr. Vine as my doctor because he has helped me so much.” Cathy angrily turned away from Brett, clearly disconsolate and distressed. She grabbed a tissue from her bag to wipe away some newly forming tears. “Why don’t you do what Marty suggests and summarize what we’ve discussed and why you think we’re here. Please let go of that ancient history. As far as I’m concerned, it was dead and buried many years ago.”

Marty intervened. It was obvious Cathy and Brett were furious with each other. He decided to look for a more neutral area in which to engage, to try to reduce the growing strain between them, but he felt the need to reassure Brett first.

“Brett, Cathy seems clear about her view of Dr. Vine, and I can reassure you that he, and his wife, Pat, have been among my closest friends for 30 years. If anything inappropriate had happened between Cathy and Dr. Vine, he would most certainly not have referred you both to me. Doctors who have affairs with patients get reported to the medical board. We both know that boundary violations in the doctor–patient relationship are unforgivable.”

“Thank you, Marty. I appreciate you saying that,” said Cathy. “Unfortunately, Brett imagines all too often that I’m having affairs whenever I’m away or on call. He makes regular accusations about several colleagues, as well as Dr. Vine. It’s true, I did have that one stupid night that I will always regret. I’m not proud of that, and Brett knows it. He just can’t seem to forgive me and move on. He’s like a dog with a bone where that one incident is concerned and constantly brings it up, blaming me for everything wrong between us. I can’t stand this continuing and have been trying really hard to change. That’s why I started seeing Dr. Vine more than 5 years ago, because we kept fighting over the famous one night!”

“Forgive me, but you must have other reasons for seeing Dr. Vine,” Marty replied. “Have you been seeing him regularly for the past 5 years? What sort of therapy or medication management has he used with you? He didn’t fill me in on your background so as not to bias me in any way. As a marital therapist, it’s best that I start my work with an open mind, not influenced by what might be inaccurate perceptions of one member of the couple. Perhaps you could tell me why you’ve been seeing him, and then we will move back to Brett and hear why he thinks you’re both here. Is that okay?”

“Certainly,” said Cathy. “From my perspective, my seeing Dr. Vine is a major part of why we’re here. I can honestly say that he has saved my life; had I not been seeing him for treatment, I think I would have eventually killed myself. I’ve been in such dark places. Brett knows all of this story, and I’ve tried to be as honest with him as possible. He’s come to see Dr. Vine with me on several occasions and knows he’s welcome to come anytime he wants. I think his jealousy of me is driven by his alcohol abuse, but he refuses to accept that.

“It took me about a year to finally build up the courage to reach out to Dr. Vine, and I only went because a surgical colleague approached me and took me out for coffee. This was one of the senior surgeons in my department, and he told me that he and several of his colleagues had become worried about me and thought I was burned out. He knew something was wrong with me. He was very empathic and respectful; he didn’t try to make me talk at length, but he did a great job of pointing out how different I’d become from the colleague he had known previously. He said that it was obvious I’d lost weight, and I was looking tired, was more irritable than usual, and seemed to be less interested in my work. He said some of the operating room nurses had also approached him about me because I’d become so touchy and quick-tempered with them, and they thought I might be depressed. Anyway, I ended up in tears in front of him in the coffee shop. It was so embarrassing. But I knew I had to do something. I talked to Brett about breaking down and thinking I should see someone professionally, and he was very supportive, of course. The perfect husband. He always is, as long as he looks good and is seen as helpful. Except in this case he didn’t know half of what I was feeling at the time, although he does now.”

Brett interrupted, speaking in a more conciliatory manner. “What Cathy says is true. She was amazing at hiding her feelings and the level of her depression at the time. I really had no idea. She’d always been so self-confident and capable; her seeing herself as weak and starting to think about suicide as the solution to her problems was something I would never have imagined. Thank goodness we had James and Sashi—I think Cathy actually might have killed herself if we didn’t.”

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