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History

A 36-year-old male administrative officer feared that his wife was about to leave him after four years of marriage. This was preceded by a six-year courtship, during which he had been reluctant to commit himself to getting married or having children.

He was an only child, and his mother, with whom he had had a close relationship, had died a year before his marriage. His wife told him that she had long since had enough of his expecting her to meet all his physical and emotional demands without offering her much in return. They were still childless, but she told him that he had become more like her child than her husband. He had refused counselling, despite her repeated requests, because he said he "did not believe in shrinks."

Presentation

He complained to their general practitioner of increasing and unbearable tension. As he had become more anxious that his wife would leave him, he would try to reassure himself that she would not do so by clinging to her desperately, and showing her how much he needed her (Stage I: mounting tension and habitual problem solving). She responded by seeing a solicitor and setting a date for their separation. He now felt that his world was "falling apart" as he could not conceive of living without her and that he must be "going crazy" (Stage II: plateau of disorganisation and stereotyped responses). He had seen another general practitioner near his workplace who had been prescribing him daily benzodiazepines for some weeks.

Intervention

Their general practitioner set another appointment time for him later that day, when they could have an extended interview. Ventilation of his distress was encouraged. A further appointment was made for both him and his wife the next evening with the general practitioner.

In consultation with the local community mental health team, expert psychiatric and marital assessment was promptly arranged, to which, in his present state of arousal, he readily agreed (Stage III: mobilisation of resources). On specialist mental state examination, a treatable ongoing psychiatric illness was excluded. He was assured of this and was relieved.

A written set of specific time-limited goals in priority order was negotiated with the man and his wife, with copies provided for each. His previously unexpressed grief over the loss of his mother was acknowledged and further counselling was offered. The differing needs of the couple and how to meet them reciprocally were briefly explored. They both agreed to provisional postponement of their separation, while a series of couple counselling sessions was arranged and completed. A clinically supervised gradual withdrawal from benzodiazepines was arranged (Stage IV: hopefully, subtype (i): adaptation and crisis resolution).

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