SETTING BOUNDARIES IN A MARRIAGE COMPLICATED BY MENTAL ILLNESS

KATHY BAYES
In a marriage where one partner is mentally ill ("MIS"), the well spouse
("WS") must aggressively set and enforce boundaries if the family is to
survive. Setting boundaries must not be confused with setting limits.
Limits are daily struggles to control undesirable behavior, some won,
some lost. Boundaries are much more fundamental and are absolutely vital
to the survival of the family. The MIS does not have an option to conform
to boundaries. They are not negotiable. These boundaries are particularly
necessary when the mental illness is chronic, but they are also important
in managing an episodic illness like manic depression. We have found
that if the WS communicates exactly what his or her expectations are
without emotion, the MIS will hear even through the static of illness AND
the chaos of psychosis. The WS must believe in these boundaries
absolutely and without a shred of doubt. The WS must also communicate
undebatable harsh consequences if the boundaries are violated.
Setting and maintaining boundaries actually improves the MIS's sense of
security, stability, predictability and order, even though the MIS may
not like some of them. Setting boundaries will encourage a more relaxed,
nonjudgmental family atmosphere. The need to set boundaries must not be
confused with the need for an understanding atmosphere. The Mental
Illness must not be allowed to dominate or grossly disrupt the household,
spinning it into chaos. If the following boundaries cannot be enforced,
then the well spouse must consider alternative care, and consider
carefully if the marriage will survive.
THE BOUNDARY OF SAFETY
First, the well spouse must ensure safety for the family. The WS's first
responsibility must be to any young children in the family. If the MIS
refuses to cooperate with doctors, participate in the treatment program,
take medication, and is abusive, the WS will not be able to stay with the
MIS. Even though well spouses believe strongly in the sanctity of
marriage and in eternal commitment [or they would have been "out of
there" a long time ago], the WS's first responsibility must be the
children. If the WS doesn't look out for the welfare of the children,
then who will?
The WS should not tolerate physical abuse. Whether this behavior is a
function of the illness or the person, it must be stopped immediately,
Sometimes medication must be adjusted to control anger and violent
behavior. This adjustment should be made immediately, or the WS should
leave until the danger has passed.
The WS should not tolerate verbal abuse. This behavior is more likely to
be a function of the illness, not the person. Regardless, it should be
stopped or controlled. The WS certainly must learn not to internalize
abuse. The WS must protect young children from verbal abuse.

THE TRUTH BOUNDARY
The Well Spouse must categorically refuse to hide the illness from
children, extended family and friends. Only if the MIS is working is
there justification for hiding the illness, and then only from work
colleagues. Not telling creates enormous isolation. Not telling and
talking creates enormous confusion for children. Not telling and talking
prevents education. Not telling and talking prevents development of good
coping skills. No Family Secrets! No Stigma! This is a biological brain
disorder. It is an Illness, like any other.
IDENTITY BOUNDARIES
In the initial experience of mental illness, the WS often is so consumed
by trying to fight a battle he or she has little knowledge of that the WS
loses his or her identity in the battle. It is like shooting darts in
the dark, with no direction, no logic, and little success, but a
tremendous gut feeling that something is seriously wrong. Often we hear
spouses say, "And I knew if I left him, he would die". They are probably
right! When the series of events and experiences is finally given a name,
efforts to control its effects can begin to take on direction and become
much more successful. After the initial diagnosis, it often seems that
everything and everyone revolves around the MIS. The WS must find his or
her identity once again, apart from the battle. The WS cannot fix the
MIS, and should quit trying. Of course, the WS can help, but he or she
must learn to let go and to find himself. Hobbies long abandoned must be
rediscovered. Interests must be cultivated, children enjoyed, talents
explored and expanded, knowledge exercised. Do nice things for yourself.
Find freedom. Demand space. GET A LIFE.
MORAL BOUNDARIES
Mental illness does -- or does not make a person a nice person, worthy of
your respect and love. The mentally ill can respect your moral
boundaries even in the midst of psychosis if you make them very clear.
If the MIS is not willing to respect the WS's value structure, then the
marriage may not survive. We do not tolerate violence, dishonesty, street
drug use, sexual unfaithfulness, and criminal behavior. The WS must
communicate grave consequences for these behaviors. The WS is deeply
committed to the sanctity of marriage, and for the MIS to violate this
value is profoundly discordant and intolerable to the WS. Often the WS's
report that "the MIS never gave me a good excuse to leave" is because the
WS's moral boundaries were never violated. That "non-occurrance" was not
an accident. Rather, it illustrates commitment by the MIS to the
marriage.
MEDICAL SYSTEM BOUNDARIES
The MIS may not want the WS to participate in treatment decisions, but
the WS must know what is going on and communicate assertively with the
doctors and therapists. The WS is the best person to communicate what is
really happening with the MIS to the doctors. The WS must know what the
treatment plan and prescribed medications are. The WS must help watch
for unwanted side effects and give feedback on the effectiveness of
medication. We have found that the WS often must push doctors into trying
new medications. The WS simply must be an expert in the treatment of the
illness and participate assertively. To not participate leaves the WS
too much in the dark. Education obtained through the Journey of Hope is
invaluable here.
PRACTICAL BOUNDARIES
The Well Spouse will probably need to take over the practical, day to day
responsibilities of the family. These responsibilities may include the
following, depending upon the severity of the illness:
1. Making sure the family has a permanent place to live. Often
Mentally ill persons will want to move and/or change jobs often, running
from the illness and failures to cope. The WS must affirmatively and
unequivocally put a stop to this constant moving. If the WS has the
finances, he/she should buy a house, put down roots, and deal with
reality.
2. Handling the finances. Most mentally ill persons do not handle
money well. This may mean withdrawing credit cards from the MIS. This
usually means setting up a separate checking account. This means paying
all or nearly all of the bills. We have found that even when the WS has
tried to share some bill paying responsibility with the MIS, it usually
fails. If the WS is a woman who is not working, she MUST get a job.
3. Handling the discipline of the children. The MIS often is very
inconsistent and unpredictable in disciplining the children, which
creates stress and confusion. The MIS may interpret misbehavior merely
because normal childhood behavior is disturbing to him/her. The WS must
establish firm guidelines, and aggressively intervene if the MIS is
totally out of line. He/she will not like it, but the damage that can be
inflicted upon young children can be irreparable. The WS will feel
confused about the best way to raise children, and may be susceptible to
pressure from the MIS, but the WS must trust his or her instincts. None
of us have all the answers, but the WS is more likely to be right. At
the same time, children should not be allowed to use Mental Illness in
the family as an excuse for disrespect and bad behavior.
4. Taking charge of home maintenance. Many mentally ill persons
simply don't see the tasks that need to be done. They also may lack the
organizational skills to make a plan to get them done. The MIS may also
lack judgment in hiring work done. Of course, the MIS should participate
in household chores, but the WS will probably have to organize it.
5. Maintaining the automobiles. The MIS may be oblivious to
mechanical difficulties and lack judgment in getting repairs done.
6. Obtaining and maintaining insurance. Often the necessity of
insurance is lost on a MIS.
7. Handling family paperwork. The MIS will lose mail, and is
probably not capable of doing income tax returns. In our household, my
husband refused to even open the mail, even though he is a licensed
attorney. He doesn't have a clue as to how I do the income tax.
8. Long range planning. The MIS is barely able to handle today, let
alone worry about tomorrow.
9. Maintaining Family Traditions. Often a MIS is stressed by family
celebrations. These events are important to the family and the WS should
not let the MIS steal them from the family, even if the stress is
uncomfortable. The MIS just has to deal with it.
HOW TO SET BOUNDARIES
1. Know yourself and what you can live with. Have confidence in your
right to demand conformance to these boundaries. Communicate them
unequivocally and unemotionally. Believe in them without reservation.
2. Be prepared to enforce consequences. Often the mere threat of
leaving scares the MIS into compliance. The MIS really knows how
dependent he or she is and how much he or she needs the WS. That is a
powerful tool for gaining compliance, to be used very selectively. Don't
feel guilty, these boundaries must be observed if the marriage and the
family is to survive. Establishing boundaries is in the best interest of
the MIS.
3. Get family support. Don't allow the MIS to "divide and conquer".
Discuss your needs with influential family members. Get them to help.
Discuss your needs with the psychiatrist and therapist, enlisting their
help. Get reinforcement and courage from your AMI support group.