I've been in full-time private practice for almost 30 years. I've seen maybe 10,000 families (it certainly feels that way.) In that time, three patients in my practice killed themselves. Strangely enough, the three suicides were eerily similar. Each suicide has left me shell-shocked and questioning my therapeutic attitudes and methods.
I did not expect Adam to be one of my casualties. He reminded me of the guys I grew up with in rural Alabama. He was large, loud and rough, masking his intelligence behind a display of anti-intellectualism and cultural ignorance. I know these guys and I've had success at retraining them, since I'm not afraid of them or contemptuous of their fragile, hypermasculine pride and their awkwardness with emotion. Like so many of the scared, bullying men I see, Adam had been trained to fail at relationships.
Adam had grown up poor and fatherless. His mother divorced his violent father when he was 12. Adam never saw him again. He didn't drink, he went to church a lot and he was an active, hands-on father to his own children. He hovered protectively, though controllingly, over Angela, his quiet, compliant wife of almost 20 years, who was a nurse. He had made a great deal of money building houses, and was now building a gigantic dream house for their large family.
Six months before I saw them, Adam had slugged his hulking oldest son for quitting his high school football team. After being advised by a counselor at work, Angela threatened divorce. Adam, baffled that she would consider leaving him after such a (to him) minor incident, suspected her of having an affair and got first paranoid and then violent, breaking furniture and punching holes in the wall with his fist. Angela went for help to a therapist, who advised separate therapy for her and Adam, as the conventional wisdom in those years was to see violent couples separately and try to get them to divorce. Angela's therapist (who never met Adam) communicated both neutrality and pessimism about the marriage, and pushed for divorce.
Adam saw a psychiatrist, who put him on Prozac, which mixed badly with his two-pot-a-day coffee habit. He became toxically irritable and, as Angela pulled further and further away, increasingly violent. For the first time in all their years together, he actually hit her. Angela's therapist advised her to call the police (I would have given the same advice). They had Adam hospitalized for a few weeks in a special program for batterers. He went willingly and was a model patient. On discharge, he went home and found Angela and his kids had moved out. He stalked her, begged her to come back and, when she resisted, beat her up. At that point, Angela called me in. She had heard I was an expert with over-the-top men.
I saw Adam, Angela, the couple and the whole family in alternating combinations. She had a court order, which, while a good idea, offered no protection. I got Adam to promise us all there would be no more violence. And there wasn't, for the remaining few months of his life. Off caffeine and Prozac, he went into a clinging, dependent depression, but was stabilized on Stelazine for paranoia, Tegretol for explosiveness and Zoloft for depression.
Angela set up a separate home for herself and the children, and put Adam on notice that she was serious about getting a divorce. I did not question her intention or try to slow her down (a failure that continues to haunt me). Instead, I used the pressure of impending divorce to spur Adam on, as I tried to teach him some manners, some sensitivity to someone else's feelings besides his own. I hoped the changes in him would bring about a reversal of Angela's resolve to get away from him permanently. I saw him often by himself, developing what I thought was a great level of intimacy, full of personal revelations, shared experiences of the rural South and humor about the changing world around us. …