Conversations with patients: Healthy marriages have irreconcilable differences

In these essays, I feature interactions I have had with my patients that I have found to be meaningful and thought-provoking. Any details about the patient’s identity have been modified to protect patient privacy and confidentiality.

Part of what I love in the work I do are the insights I gain from the relationship with a patient. Come to think of it, to have a relationship where both parties feel changed for the better is extraordinary. I am so blessed to have this possibility in my work.

On this day, my patient, Cora, was scheduled as my last appointment of the day. Seeing this, I could feel myself relax a little. It is because I have seen Cora for about 1 year, and she is one of the most optimistic and lovely people I have met. She is in her 70's, has been married to the same man for 56 years, and is a mother and grandmother. She is always full of gratitude. When I first met her, I knew she would certainly be teaching me a thing or two about life and not the other way around.

Cora was referred to me after experiencing intense mood swings that had worsened since starting treatment for a rare and terminal illness. Prior to this, she was a spirited gymnastics coach who loved to bake pies for friends and neighbours. She told me that when she was healthier, being productive was a core part of her identity and pride. She still had this spirit, that was plain to see, but with this illness, Cora's body had begun to weaken. She became short of breath and prone to falls. The treatment took away her appetite and energy. It was becoming clear to Cora that the illness was progressing. Cora was dying.

For most of our time together, I was trying to assess her moods to see if a change in medication was warranted. It is very difficult to tease out the cause of symptoms when the illness, the treatment and aging can all contribute. Typically, Cora would tell me how she had a difficult day or two but she still had enough fight to live a good life. In light of this, no changes were needed to her medications so far.
At this appointment, the day of low mood became a week and she reported something new, the feeling of deep regret over things in her past she normally did not think much about. Spontaneously, she told me about her adolescence. She had become pregnant out of wedlock and though the father of the baby had promised to marry her, within 2 months of the baby's birth, he announced his engagement to another woman in the local paper. Cora was devastated. Fortunately, she found a man who would love and marry her and adopt her son, but things were not easy and there was tension between the two of them over how to manage the relationship with the baby's biological father. The arguments became so heated that they were on the verge of a separation. Things cooled off when Cora and her family moved to another town. Cora does not doubt she is with the love of her life, but to this day, there are topics she dare not bring up because of the conflict that would follow. Since she had last seen me, she was losing sleep over how she had treated her husband in the past, these feeling made worse with how well he was treating her now.

There was so much to take in from her story and her resilience, but my priority was her worsening mood state. I felt very deeply that it was unacceptable for this woman to suffer at the end of her life from guilt that did not seem appropriate. This to me was an early warning sign for a clinical depression and so I made some changes to her treatment and will see her with more frequency. I asked her to challenge her guilty thoughts, as it was also evident to me throughout their marriage, that Cora took very good care of her husband.

This conversation with Cora was remarkable to me because it was the first time I had heard about an irreconcilable difference in a relationship that was happy, healthy and sustaining. And it has changed how I look at my own relationships. When we commit to someone forever romantic or platonic, it seems that we are bound to accrue irreconcilable differences over time, but it is how these differences stack up against what matters in the bigger picture that determine their impact on a relationship. Afterall, the person one chooses for the big things and the person one chooses for the little things do not have the same criteria. We initially choose a partner for the laughs and good times, but who we want to end up with is the person who will be your main support through the major tragedies in life, tragedies that have not yet occurred, but will be devastating. So what if he annoys me or we do not like each other from time to time? This just pales in comparison to what we are up against as time marches on, I hope to be as lucky and strong as Cora and her husband.

Most patients psychiatrists have to keep because they need the medical care. Then there are the patients like Cora, who I keep for me.