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    Not Getting Better? Insist Upon The Biopsychosocial Model (Part 3)

    The Role of Genetic Testing Under The Biopsychosocial Model

    Despite the fact that Sandra was in crisis and desperately longed for Sam to be more emotionally available, his anxieties over the possibility of losing his job, combined with his fears that she would lose her own job as well (she was not fulfilling the minimum billable clinical hours at the hospital) kept him from being more emotionally available to her following her discharge from the hospital. His longstanding difficulties with emotional intimacy, resulting from his troubled relationship with his mother, also complicated the picture. Sam resisted getting into individual or couple’s therapy to resolve these issues, despite my urging (at times imploring) him to do so.

    “Sam, I really fear that Sandra will not recover from her depression while remaining married to you, and that the gulf between you will only widen, if you do not get help to resolve your conflicts over intimacy and dependency.” Their marriage was deteriorating, and despite my interventions, they both seemed hell bent on destroying it. It wasn’t clear what either of them wanted, or whether I could help them at all.

    In retaliation for Sam’s refusal to get help, Sandra began going out more frequently at night with her friends, and began to have a series of affairs. Her alcohol consumption increased and she began to dabble in cocaine use. Her mood swings became more severe and we increased the frequency of her visits with me, and placed her on an additional mood stabilizer, Lamictal (lamotrigine) [iii][iv] that also had antidepressant effects, and began her on a prescription vitamin, l-methylfolate, that increased the manufacture of dopamine, norepinephrine and serotonin levels in the brain. These two medications were selected as a result of Genecept™ genetic testing [vi] which revealed two genetic variants, a variant in the production of Methylene Tetrahydrafolate Reductase “MTHFR,” and a variant in sodium channel activity. These variations predicted a response to l-methylfolate and Lamictal, respectively.

    While she had no prior history of mood swings and there was no family history of bipolar disorder, I began to wonder about the possibility that underneath it all Sandra had a bipolar illness. As well I began to fear that she might harm a patient under her care, which would then result in her losing her medical license. I implored her to get involved in a Twelve Step program to address her emerging substance abuse problem, and she adamantly refused to even consider the idea. Each session I would encourage her to attend AA meetings but she objected, and also declined to enroll in a local outpatient drug and alcohol treatment evening program that would work with her schedule. Sandra was in denial that she had a substance abuse problem, and threatened to leave treatment if I continued to press her on the issue. So I backed off, fearing that her downward spiral would only worsen and lead to suicide if she dropped out.

    At the same time, it was clear that we had not as yet uncovered and talked through some unidentified psychological conflicts. And for some reason what suddenly came to mind was a refrain from that Coldplay song “Paradise,” where Chris Martin sings about how life goes on and gets so heavy, the wheel breaks the butterfly, and every tear is a waterfall. Something in my own unconscious was telling me that Sandra had once been a butterfly who had been broken by life, which gave me insight as to where we had to go in Sandra’s therapy, and what her drinking and drug use behaviors were covering up.

    In this instance some deep emotional issues were tearing Sandra apart and driving her self-sabotaging behavior, which was an effort to avoid facing some profound aspects of her feelings and herself that were still unconscious. Patiently, and with me feeling a great deal of worry inside as to whether she would stay alive long enough for us to find out what she was avoiding, I asked her if she would be willing to focus on her mother’s illness and death, and to share with me everything she had been feeling during those horrifying years of her mother’s decline. Sandra was reluctant to proceed, so I offered to see her twice-a-week, and gave her my mobile telephone number, to help her feel more emotionally supported. Armed with this additional support, and feeling much dread inside, Sandra embarked upon this next, and most important, phase of her therapy.

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