If you are just picking up on this series, you might do well to start by reading at least the last post. Today's post will refer extensively to the last one.
To review where we are in this "case study," Robert has come to my office about 36 hours after meeting a woman. He and she have fallen in love at first sight. Robert was in a Major Depression until meeting her. His condition is now one of anxiety verging on panic.
The couple's situation is fraught with dangers. Julia is soon to return to a Portuguese island and possibly marry a man there. Both Robert's and Julia's families are at odds with each other. Each of the families would forbid the marriage. Last, and certainly not least, Robert could fall back into a severe depression if the new relationship fails.
Just as Romeo sought out Friar Lawrence to help him solve his dilemma with Juliet, Robert has come to my office to get help with his situation.
This is a tricky case to bring to a successful conclusion. Robert wants a quick and practical solution. He insists on planning his elopement and later announcing the fait accompli to their families. He is not seeking on-going therapy. Robert believes that all he needs to do is marry his love, tell the families and the rest will more or less sort itself out. He is an impetuous young man. Robert will not tolerate me dilly-dallying with clinical nuances.
In Shakespeare's play, "Romeo and Juliet", Friar Lawrence provides the service that Romeo requests: help getting married. To be fully fair to the Friar, he does say to Romeo "Go wisely and slowly. Those who rush stumble and fall." [Act 2, Scene 3, Page 4] But, despite any misgivings, the Friar marries the couple.
This course of action has a terrible outcome. Romeo, as we know, suicides when he believes that his new bride is dead.
"Come, bitter poison, come, unsavory guide! You desperate pilot, let's crash this sea-weary ship into the rocks! Here's to my love!
ROMEO drinks the poison.
Oh, that pharmacist was honest! His drugs work quickly. So I die with a kiss." [Act 5, Scene 3, Page 5]
From a clinical point of view, this tragic end came from overlooking both the underlying psychological conditions and the real external stressors. Marrying Juliet may temporarily alleviate Romeo's anxiety. The marriage gives him the false belief that the external dangers are vanquished. Moreover, eloping does not address Romeo's vulnerability to severe depression.
In one sense, it would be easy to help Robert problem solve an elopement. Let's play this option out for a moment.
After all, I am human. It would be hard to resist this good looking, articulate young man's impassioned pleas for help now, today. Then there is his seductive, raw belief in true love. On another front, if I practiced in an HMO or a capitated system, there would be pressure to get this case done with the least expenditure of resources. Long gone are the days when the first four sessions were considered to be the initial evaluation. Active treatment started only with the fifth session after an exhaustive collection of psychosocial history and mental status evaluation. That was then.
Quite possibly, Robert's treatment could be completed in the first session. I open my laptop computer and google "marriage requirements RI." Google then helpfully provides me with the link to About.com's summary of the Rhode Island marriage laws. The requirements, as it turns out, are pretty simple.
My next step is to print the page and give a copy to Robert. Together, we plan how he and Julia can meet each of the steps necessary to get married. I encourage Robert to take written notes on the back of the page. Ten minutes later, we are done. Robert feels a great sense of relief to have a concrete plan. He thanks me profusely and leaves without scheduling another appointment. I have a sense of satisfaction in providing almost immediate relief for his symptoms and giving him the treatment that he requested.
The technique of improving a patient's problem solving abilities is certainly a valid clinical tool. According to Wikipedia, this method has been studied for over 100 years. Mills, Reiss, and Dombeck have written about improving a person's "self-efficacy." This is the "belief in your own effectiveness as a person, both generally in terms of managing your life, and specifically with regard to competently dealing with individual tasks." Positive self-efficacy helps to "decrease people's potential for experiencing negative stress feelings by increasing their sense of being in control of the situations they encounter." Thus, the choice of improving Robert's problem solving skills for the task of getting married to Julia appears, at first glance, to be a good tactic.
However, I would do well to recall Romeo's fate in my treatment recommendations for Robert.
As Mills, Reiss, and Dombeck also point out, "The perception of being in control (rather than the reality of being in or out of control) is an important buffer of negative stress." In Robert's case, helping him to problem solve how to elope only improves his perception of being in control. It does virtually nothing to address the real world stressors and his risk for depression.
Moreover, the odds are that the passion will fade for Robert and Julia. Acevedo and Aron studied various types of love and the outcomes in their article "Does a Long-Term Relationship Kill Romantic Love?" They found that:
"Results from the factor analysis and correlations with satisfaction support the notion that in long-term relationships, romantic love and obsession are quite distinct: Romantic love (without obsession) is positively associated with relationship satisfaction, but the obsessive aspect is negatively associated with it." (p.61)
At the time when Robert enters the office, he is quite obsessed with Julia and his quest to marry her. He barely mentions her personal qualities. In fact, Robert and Julia know very little about each other. They have little information or shared experiences upon which they can ground their romance.
As Friar Lawrence observes about Romeo's love for Juliet: "Young men's love then lies Not truly in their hearts, but in their eyes." [Act 2, Scene 3, Page 3]
Acevedo and Aron's work indicates that even without the tragic outcome in the play, Romeo and Robert's loves are likely to be short-lived.
Problem solving the elopement, then, is likely to yield only a temporary relief of anxiety and leave the much bigger problems lurking in the background.
The following is my own impression and is not a valid legal opinion. If a clinician did choose this route, I do not see that the families would have any firm basis for legal recourse against the clinician. The practice of improving problem solving and self-efficacy is well established. In addition, there are many, many intervening variables between the time of the interview and the outcomes of either suicide or falling out of love. Those variables would make it difficult to pin the blame on negligent treatment. In the lawsuit of Palsgraf vs. Long Island Rail Road, an employee helped a man get on a moving train. This resulted in a domino effect ending with the injury of a woman. The court ruled however "If the harm was not willful, he must show that the act as to him had possibilities of danger so many and apparent as to entitle him to be protected against the doing of it though the harm was unintended." The families, I think, would be hard pressed to show that the clinician either intended harm or could reasonably see the "possibilities of danger so many and apparent."
In summary, helping Robert problem solve his elopement would be what Robert wants. A "successful" one-session treatment would please any cost-conscious administrator. Problem solving is also a well-documented clinical strategy. There seems to be little legal risk to the tactic.
However, for all the reasons mentioned above, it would be in Robert's best long-term interests not to give him what he thinks he wants. The trick is going to be in convincing Robert to tolerate the anxiety and hold off on his impulsive plan.
In the next post, we will investigate other treatment options for Robert.