Noteworthy News Articles on Mental Health Topics, August 1-12, 2007

Caitlyn, who is 13, and Marguerite, who is 16 (I’ve used only their first names to protect their privacy), held yellow sheets of paper on which they had written their answers. It was the third day of the weeklong camp, late for icebreakers. But the Hawks are kids with autistic disorders accompanied by a normal or high I.Q. And so the main goal of the camp, run on a 26-acre ranch by a Utah nonprofit organization called the National Ability Center, is to nudge them toward the sort of back and forth — “What’s your favorite video game?” — that comes easily to most kids.

Along with Caitlyn and Marguerite, there were nine boys in the camp between the ages of 10 and 18. They also sat across from one another in pairs, with the exception of one 18-year-old who was arguing with a counselor. “All I require is a purple marker,” the boy said over and over again, refusing to write with the black marker he had been given. A few feet away, an 11-year-old was yipping and grunting while his partner read his answers in a monotone, eyes trained on his yellow paper. Another counselor hurried over to them.

Marguerite was also reading her answers without eye contact or inflection. “My favorite vacations were to India and Thailand my favorite thing about myself is that I’m nice to people if I could choose any superpower I’d be invisible,” she said in an unbroken stream. She looked up from her paper and past Caitlyn, smoothing her turquoise halter top over the waist of a pair of baggy cotton pants. Caitlyn was also staring into the middle distance. She has gold-streaked hair, which was bunched on top, and wore a black T-shirt with a sunburst on the front and canvas sneakers with skulls on the tops. The girls didn’t look uncomfortable, just unplugged.

A counselor noticed their marooned silence and prodded Caitlyn to take her turn. At first, she ran quickly through her answers, too. But Caitlyn loves fantasy — she is an avid writer of “fan fiction,” spinning new story lines for familiar characters from “Pokémon” and “Harry Potter” — and the superpower question grabbed her. She looked at Marguerite. “If I could have any power, I’d want to be able to transform into an animal like a tiger,” she said, smiling and putting her hands in front of her face, fingers tensed as if they were claws. Marguerite smiled and tentatively mirrored the claw gesture. Caitlyn smiled back. “I like tigers,” she said, her eyes bright behind her glasses. “Do you?”

It was a small, casual encounter and also an exceedingly rare one — a taste of teenage patter shared by two autistic girls.

Autism is often thought of as a boys’ affliction. Boys are three or four times as likely as girls to have classic autism (autism with mental retardation, which is now often referred to as cognitive impairment). The sex ratio is even more imbalanced for diagnoses that include normal intelligence along with the features of autism — social and communication impairments and restricted interests; this is called Asperger’s syndrome (when there is no speech delay) or high-functioning autism or, more generally, being “on the autistic spectrum.” Among kids in this category, referral rates are in the range of 10 boys for every girl.

According to the Centers for Disease Control, there are about 560,000 people under the age of 21 with autism in the United States. (Adults aren’t included because there is no good data on their numbers.) If 1 in 4 are female, the girls number about 140,000. The C.D.C. estimates that about 42 percent of them are of normal intelligence, putting their total at roughly 58,000 (with the caveat that these numbers are, at best, estimates).

Because there are so many fewer females with autism, they are “research orphans,” as Ami Klin, a psychology and psychiatry professor who directs Yale’s autism program, puts it. Scientists have tended to cull girls from studies because it is difficult to find sufficiently large numbers of them. Some of the drugs, for example, commonly used to treat symptoms of autism like anxiety and hyperactivity have rarely been tested on autistic girls.

The scant data make it impossible to draw firm conclusions about why their numbers are small and how autistic girls and boys with normal intelligence may differ. But a few researchers are trying to establish whether and how the disorder may vary by sex. This research and the observations of some clinicians who work with autistic girls suggest that because of biology and experience, and the interaction between the two, autism may express itself differently in girls. And that may have implications for their well-being.

The typical image of the autistic child is a boy who is lost in his own world and indifferent to other people. It is hard to generalize about autistic kids, boys or girls, but some clinicians who work with high-functioning autistic children say they often see girls who care a great deal about what their peers think. These girls want to connect with people outside their families, says Janet Lainhart, a professor of psychiatry and pediatrics at the University of Utah who treats Caitlyn and Marguerite. But often they can’t. Lainhart says that this thwarted desire may trigger severe anxiety and depression. Other specialists are not sure that girls struggle more in these ways. “This is a profile of both boys and girls,” Klin says of the wish to connect that some people with autism have. But he agrees with Lainhart that it is easier for Asperger’s boys to find other boys — either on or off the autistic spectrum — who want to spend hours on their Game Boys or in a realm of Internet fantasy. Klin and Lainhart also say they think that the world is a more forgiving place for boys with the quirks of Asperger’s because, like it or not, awkwardness is a more acceptable male trait.

This gender dynamic doesn’t necessarily affect girls with Asperger’s when they are very young; if anything, they often fare better than boys at an early age because they tend to be less disruptive. In 1993, Catherine Lord, a veteran autism researcher, published a study of 21 boys and 21 girls. She found that when the children were between the ages of 3 and 5, parents more frequently described the girls as imitating typical kids and seeking out social contacts. Yet by age 10, none of the girls had reciprocal friendships while some of the boys did. “The girls often have the potential to really develop relationships,’ says Lord, a psychology and psychiatry professor and director of the Autism and Communication Disorders Center at the University of Michigan. “But by middle school, a subset of them is literally dumbstruck by anxiety. They do things like bursting into tears or lashing out in school, which make them very conspicuous. Their behavior really doesn’t jibe with what’s expected of girls. And that makes their lives very hard.”

No doubt part of the problem for autistic girls is the rising level of social interaction that comes in middle school. Girls’ networks become intricate and demanding, and friendships often hinge on attention to feelings and lots of rapid and nuanced communication — in person, by cellphone or Instant Messenger. No matter how much they want to connect, autistic girls are not good at empathy and conversation, and they find themselves locked out, seemingly even more than boys do. At the University of Texas Medical School, Katherine Loveland, a psychiatry professor, recently compared 700 autistic boys and 300 autistic girls and found that while the boys’ “abnormal communications” decreased as I.Q. scores rose, the girls’ did not. “Girls will have more trouble with social networks if they’re having greater difficulty with communication and language,” she says.

And so girls with autism and normal intelligence may end up at a particular disadvantage. In a new study published in May, a group of German researchers compared 23 high-functioning autistic girls with 23 high-functioning boys between the ages of 5 and 20, matching them for age, I.Q. and autism diagnosis. Parents reported more problems for girls involving peer relations, maturity, social independence and attention.

The difficulty may continue into adulthood. While some men with Asperger’s marry and have families, women almost never do, psychiatrists observe. A 2004 study by two prominent British researchers, Michael Rutter and Patricia Howlin, followed 68 high-functioning autistics over more than two decades. The group included only seven women, too small a sample to reach solid conclusions about gender differences, Rutter and Howlin caution. But 15 men — 22 percent of the sample — rated “good” or “very good” for educational attainment, employment, relationships and independent living, while no women did. Two women rated “fair,” compared with 11 men, and the other five women were counted as “poor” or “very poor.” None had gone to college. None reported having friends or living on their own. Only one had a job. Undermined by anxiety and depression, women with autism appear to be more often confined to the small world of their families.

When Caitlyn started kindergarten and didn’t play normally with other kids, her mother, Juli, thought it was because she hadn’t gone to preschool. The first warning of real trouble came from the first-grade gym teacher, who told Juli that Caitlyn exposed herself to the class. Caitlyn is overweight, and she has always been private about her body. Juli couldn’t imagine her daughter taking off her clothes in public, and when she asked what had happened, Caitlyn said another girl had pulled down her pants. “Caitlyn stood there mortified,” Juli says. “But she couldn’t express that to the teacher.”

Caitlyn lives with her mother, her older sister, the girls’ great-grandparents and a pair of poodles in Farmington, outside of Salt Lake City. (Her father died before she was 2.) Until second grade, Caitlyn had a neighborhood friend with whom she went to school. Other than that, she was often alone in class. Her teachers were frequently frustrated with her inability to work and play in groups. But she connected with a few adults — in fifth grade, one class aide took her horseback riding, and the school librarian gave Caitlyn her own copy of “Spindle’s End,” a retelling of “Sleeping Beauty,” “because she said I helped her so much,” Caitlyn remembers.

Contrary to the Asperger’s stereotype, Caitlyn struggles in math but tests in the highly gifted range in reading and writing. This is another sex difference that Lord sees among her patients. “I don’t have any real data, but a lot of high-functioning girls are real readers — not great on subtleties, but they like fantasies and the ‘Baby-Sitters’ series,” she says. “The boys are much less so.”

In elementary school, Caitlyn went to special-education classes for math and social skills. At 11, as other girls began to slip out of reach, Asperger’s was diagnosed. The shift a year later to junior high for seventh grade was a jolt. By the second week of school, a few boys were mocking Caitlyn’s weight and calling her weird while other kids laughed. “No one would sit by me at lunch,” Caitlyn says. Girls told her that they didn’t want her to be in their reading group. Caitlyn did her homework, but she was too anxious to walk to the front of the room to turn it in. At home, her neighborhood friend no longer came out to play.In the winter, Caitlyn switched from a special-education math class into a mainstream one, and the kids in her new class made her miserable. For days she refused to go to school. She told Lainhart: “No one likes me at lunch. I’m very sad.” (With Juli’s and Caitlyn’s permission, I read Lainhart’s notes on Caitlyn’s treatment.) After a huge outburst of anger at home, Caitlyn told her mother that she wanted to die. At her next appointment with Lainhart, she said: “I listen to people’s conversations during free time in science. They talk about live games, R-rated movies, outfits. I feel left out.” Caitlyn told Lainhart about two dreams. In one, her school had a bridge running through it, and she kept falling off. In the second, she was in the lunchroom throwing a party; no one came. Lainhart says that while boys are aware of rejection and bullying, in her experience they are not hurt by it to the extent that some girls are. “I have rarely had a male patient with autism become suicidal or express such intense emotional pain,” she says.

Caitlyn has never hit another child. But at school, her retorts to her peers — “I yelled at a . . . little bimbo. They yelled at me,” she told Lainhart during one appointment — pushed them further away. With Lainhart’s help, Juli persuaded the school to let her daughter eat lunch in a classroom rather than in the cafeteria. Still, Caitlyn’s grades dropped from A’s and B’s to D’s and F’s. Her anxiety level spiked, and her sadness bloomed into depression.

Lainhart has seen the same blend of anxiety and depression in other female patients. Like Caitlyn, Marguerite’s serious problems date from middle school. In sixth grade, she moved to Salt Lake City and away from a couple of strong friendships, and she couldn’t replace them. “She found it increasingly difficult to do the things necessary to maintain friendships with ‘normal’ kids,” her father says. Last fall, at 15, she withdrew further. An olive-skinned girl with thick brown hair — she was adopted from Guatemala as a baby — Marguerite has always liked to go shopping and wear pretty things (not a typical trait for a girl with autism, though not unique either). But she stopped dressing herself, washing her hair and going to school. For months, Marguerite spiraled into one of the worst bouts of depression Lainhart has ever seen.

Since 1990, when she was recruited to work with autistic children by Susan Folstein, a prominent Johns Hopkins researcher, Lainhart has been interested in the relationship between autism and depression. In a 1994 paper, Lainhart and Folstein pointed out that despite the 4-to-1 male-female ratio for autism, females made up half the autistic patients with mood disorders described in the medical literature. The case reports may not represent the population as a whole; still, the overrepresentation is suggestive. Lainhart is currently looking at the relationship between autism and depression in boys and girls and the potential link to depression in their parents and siblings. “We know that anxiety and depression are co-morbid,” meaning that they occur together, Lainhart says. “And we know that depression is worse for women in the general population. But what’s the link to autism? And is it worse for girls?”

Social anxiety affects Lainhart’s female patients into adulthood. Liz Lee, who is 43, is studying for her master’s degree in electrical engineering, yet she cannot cope with going to lunch with the other graduate students at the lab where she works. Ash Baxter, who is 22, spends hours making art, sewing dolls with wild yarn hair and macramé-edged suits; she created an extraordinary blue-and-gold octopus mask out of a three-foot gourd she found in the garage. She is talented and would like to attend art school, but Baxter can’t master her anxiety well enough to learn to drive or live in a dorm, so college art classes remain out of reach. Another patient, Charlotte (she asked that I not use her last name) is 23 and goes to a social-skills class that Lainhart runs for her patients in their late teens and early 20s. Because of the dearth of females, the class is mostly male, and Charlotte often leaves in the middle saying she’s “stressed out.” “She can only take so much,” her mother told me. Lainhart says, “You see these incredible areas of anxiety in Liz and Charlotte and Marguerite that don’t seem to have a parallel in the boys and men.” There is preliminary evidence that girls and women also vary from the male Asperger’s profile in terms of their interests, as Catherine Lord suggests. David Skuse, a psychiatry professor at the Institute of Child Health at University College London, has analyzed data from 1,000 children, 700 of them on the autistic spectrum. “Girls with autism are rarely fascinated with numbers and rarely have stores of arcane knowledge, and this is reflected in the interests of females in the general population,” Skuse explains. “The girls are strikingly different from the boys in this respect.”

With her high aptitude for reading and writing and her difficulties with math, Caitlyn fits Skuse’s model. Even as she was failing school last year, she kept up her fan fiction, posting stories she had written on the Web site Gaia Online. On the 40-mile drive home from camp, she told me about her plan to write an original eight-book fantasy series about a werewolf, to be called “Midnight Wind.”

One of the best-known theorists on sex difference and autism, Simon Baron-Cohen, comes at these questions from another angle. A psychology professor and director of the Autism Research Centre at Cambridge University, Baron-Cohen has characterized autism as a condition of the “extreme male brain.” His research shows that in the general population men are more likely than women to score low on a test of empathy and high on a test of recognizing rules and patterns, or “systemizing.” High systemizing together with low empathy correlates with social and communication deficits and, at the extreme end of the scale, with autism. Baron-Cohen is currently studying whether elevated levels of fetal testosterone — a prime driver of masculinity — are linked to autistic traits.

Baron-Cohen says that he believes that autistic girls are strong systemizers. That quality may manifest itself in letters rather than numbers. But in his view, the thought processes for Asperger’s girls mirror those of boys. He explains, “These females often feel more compatibility with typical males simply because typical males may be more willing to adhere to the linear, step-by-step form of thinking and conversation — more like debating or playing chess or doing logic.”

To Lainhart, Baron-Cohen’s extreme-male-brain theory is an apt description for a subset of her female patients, for example Liz Lee, who in pursuing electrical engineering is training for a classic Asperger’s profession. Lee is socially aloof: she usually sits on the floor with her back to Lainhart during their sessions, twirling the propeller of a toy helicopter. Eye contact makes Lee angry, and she says she would like to live alone in the desert.

But based on their clinical experience, Lainhart and also Skuse see autism as a heterogeneous disorder. Its profile may change and expand as more is understood about girls, whose autism, they worry, often goes undiagnosed. That is partly, Skuse posits, because girls’ general aptitude for communication and their social competence helps some Asperger’s girls “pass” — they pick up on their difference and carefully mask it by mimicking other girls’ speech and manner and dress. In a sense, their femaleness allows some girls to seem less autistic. It is as if they start off with a social advantage — Skuse sees this as a 20-point bonus on a scale of 100 — that helps counter the disorder. This idea isn’t necessarily at odds with the findings that show girls to be more seriously affected by autism, Skuse says, because the girls who succeed in masking their deficit wouldn’t be included in studies. And so they are missing from the picture. “There is no doubt in my mind that the way we have defined autism currently biases our assessments strongly in the direction of identifying a male stereotype,” he says. The C.D.C. agrees and says that as a result the estimate for the number of girls with autism and normal intelligence may be low.

Why would autism express itself differently depending on sex? The short answer is that no one knows. Genetic researchers, however, have just begun to hint at possibilities. In the last two years, new data-pooling efforts have yielded two major genetic-linkage studies — attempts to link autism to specific chromosomes — that suggest that some of the genes underlying autism may be different in males and females. By isolating sex as a variable, scientists are seeing potential genetic hot spots for autism. “By comparing males and females, we will have a much better chance of discovering the causes of autism,” says Geraldine Dawson, a psychology professor and director of the University of Washington Autism Center, who was a co-author of one of the studies.

Studies that use the latest brain-scanning tools — magnetic resonance imaging and diffusion tensor imaging — generally focus on boys. But a single study of M.R.I.’s of both boys and girls found differences in their brain anatomy. Published in April in The Journal of the American Academy of Child and Adolescent Psychiatry, the study compared nine girls and 27 boys who were matched for age, I.Q. and severity of autism. Other research has established some correlation between abnormally large brain size and autism; the April paper reported that the brain volume of the autistic girls deviated from the norm more than the volume of the autistic boys. Lainhart, who is a member of the University of Utah’s Brain Institute, has measured head circumference as a proxy for brain volume. (The two are linked.) In a 1997 paper, she reported that the mean head circumference of eight autistic girls at birth was significantly greater than the norm, whereas the mean head size of 37 autistic boys was not.

These are small and preliminary studies, but their findings may relate to a puzzle of autism: while overall, there are more mentally retarded autistic boys than girls, a greater proportion of autistic girls are retarded — 58 percent compared with 42 percent for boys, according to the C.D.C. As for Asperger’s girls, Lainhart, who continues to conduct brain research, says she hopes eventually to shed light on the deficits of girls like Caitlyn and Marguerite and suggest new treatments for them. “In children with dyslexia, scientists identified where the basic cognitive deficits were,” she says. “Then they intervened to go after those deficits, and they saw the brain change in those areas.” In the meantime, girls with autism and normal I.Q.’s pose a particular challenge for schools. Though mainstreaming has its benefits, autistic kids risk becoming outcasts in a regular classroom. Yet if girls go to a special-education program or a separate school, they are often swimming in a sea of boys. Lord pointed to this as a factor in girls’ lack of friendships in her 1993 study. When the girls in her sample were shifted to specialized programs, “their opportunities to meet girls and women with some common interests were even more limited than those of the boys and men,” she wrote.

The Harbour School in Baltimore has tried to address this predicament. The school has 120 students, all with learning disabilities, speech impairments, attention-deficit disorders and autistic-spectrum disorders. Only 19 of them are girls, which leaves one or two in each class from first to 12th grade. (More boys than girls are also diagnosed with the hyperactive form of A.D.D. and some learning disabilities.) Along with the playful Baltimore street scenes that decorate the walls of the hallways at Harbour, the predominance of gangly male bodies and loud voices was the first thing I noticed on a recent visit. The school felt like a haven — for boys.

And so I wondered whether the girls would feel overwhelmed, as Charlotte often is at her mostly male social-skills class. In the school auditorium at about 9 a.m., there were 13 sixth graders — 12 boys and a single girl, Krissy, whose clinical designation is pervasive developmental disorder on the autistic spectrum. She was sitting on the floor playing Connect Four with one of the boys. She won her game, smiled without looking at her opponent, then got up and walked across the room to another of her classmates.

“Hi, Michael,” she said. He didn’t look up. Krissy sat down next to him and watched him play on his Game Boy. They talked quietly about his progress; she knew the game. A few minutes later, she found her Connect Four partner again, and they decided to play Operation. They talked about the rules, but when Krissy tripped the buzzer, he let her finish taking out the body parts she was maneuvering. Krissy declared victory and moved on again, this time to lie on the floor next to a boy who was building with metal rods and blue glass balls.

“Do you need help?” she asked him.

“No,” he answered.

“Can I at least play with you?” Krissy persisted. The boy grunted. Without talking more, they each built a structure.

Krissy has been at Harbour since first grade, and the small size of her class means that she knows the boys well. Her teachers say she is at ease with them because she shares their Game Boy enthusiasm and watches the same movies. But sometimes Krissy’s interests seem entirely girlish. She was excited about straightening her hair and then styling it into corkscrew curls for her interview with me and showed off pictures she had drawn of princesses, covered with hearts.

Harbour makes a concerted effort to give its girls the chance to develop relationships with one another. The girls’ lunch periods coincide to give them time together. A social worker, Kelli Remmel, runs a regular “girls club” for a group of about half a dozen. “There are some things the girls don’t want to discuss in front of their male peers,” she says. “It’s a chance for them to talk about boys, how to handle hormonal changes, other girls, their bodies, dating.”

Krissy seems to be getting the social opportunities and support that Lord and Lainhart want for the girls they treat. Salt Lake City has good schools for kids with Asperger’s, Lainhart says, but the catch is money. School districts in Maryland, Washington and Virginia pay Harbour’s tuition for more than 95 percent of the students. But districts in many parts of the country — including Utah — don’t pay for private-school placements for kids with Asperger’s. Caitlyn doesn’t go to a school like Harbour because her family can’t afford it; her experience, not Krissy’s, is typical.Lord and Lainhart try to help by setting up social-skills groups for their patients. But families must pay for the classes out of pocket because medical insurers generally don’t pay for treatment and services that focus on autism — a terrible problem for her patients, Lainhart says. So the groups tend to meet only a couple of times a month for a few hours. Charlotte doesn’t know the boys in her group the way Krissy knows her classmates. At the University of Michigan, Lord runs co-ed groups for younger children and then tries to put together groups of older girls that mix autistic and nonautistic kids. As the girls get older, it is harder to find normally developing girls who want to participate. Twenty years ago, as a clinical psychologist in Canada, Lord started a group of four Asperger’s girls who stayed in touch into adulthood. They called themselves the highest-functioning autistic women in Canada, she remembers, and treasured their solidarity. “It’s striking how much girls with autism can care about each other and other people and develop friendships that are really a source of joy for them,” Lord says. “But when I think of the teenage girls I know, many of them have no shot at forming those relationships.”

At the Hawks Camp in Utah, Caitlyn and Marguerite didn’t become friends. A week earlier, Marguerite and Lainhart had made a list of conversation starters, but Marguerite didn’t really use them. Caitlyn didn’t try to talk to her much, either. The camp lasted only a week; for these girls, not long enough for bonding. Still, Caitlyn said it was the best week of her year. One day after lunch, the Hawks campers drove in two minivans to a nearby lakefront to go tubing and Jet Skiing. Caitlyn changed into her bathing suit, then wrapped herself in a towel despite the strong hot sun. “Do I look O.K.?” she asked a counselor. “It’s just that there are so many people.”

But the other kids were paying Caitlyn no mind. This wasn’t a group that Caitlyn had to fear. She balled her hands into fists, visibly holding her anxiety at bay. “Sometimes I feel like I’m weird and ugly,” she said, “but I’m not going to today. I’m confident!” She strode out to Jet Ski and later returned with a description that she planned to use in a future story: “It was like riding a dragon through the storm.”

Back at camp, the Hawks poured onto the playground. During the school year, Caitlyn had been excused from gym class because she was so nervous about changing her clothes and running around in front of her classmates. As she sat on a swing and watched kids play tag, a counselor named Claire came over. As she and Caitlyn talked, Caitlyn did all the tiny things that people do to engage one another, smiling, laughing, gesturing, looking Claire in the eye. Claire urged her to join the game and called out, “Caitlyn’s playing!” Caitlyn protested. But Claire persisted, and finally Caitlyn yelled, “O.K., where’s the base?” A teenage boy pointed to the monkey bars, and Caitlyn ran for it. Her glasses slipped off her nose, and her shorts slipped a bit, too. She hiked them up and kept running, surrounded by other kids. Sweating and laughing, she yelled, “Safe!”

Counseling by Phone Benefits Drinkers
Eric Nagourney, New York Times- 8/7/2007

Experience has shown that even a few short discussions with a health professional can help a problem drinker. But sometimes people who could benefit from the talks are unable to come in or reluctant to do so.

Maybe they do not have to, says a new study that found that counseling by telephone could be effective in curbing excessive drinking.

Writing in the August issue of Alcoholism: Clinical and Experimental Research, researchers suggested such counseling could be good for hard-to-reach patients. It also uses fewer resources than face-to-face meetings.

“Telephone counseling for alcohol problems,” the authors write, “could help overcome barriers that often hinder access to conventional alcohol treatment such as stigma, transportation, child care and scheduling conflicts.”

The researchers, led by Dr. Richard L. Brown of the University of Wisconsin School of Medicine and Public Health, screened patients in waiting rooms at 18 Wisconsin clinics and contacted those who appeared to have a possible alcohol problem. In all, the team worked with almost 900 people, half of whom were given just pamphlets and the remainder receiving counseling.

The program seemed to work better for men than for women. The men reported an overall decline in drinking of 17 percent, the women 11 percent.

The researchers said they were surprised at how readily many patients agreed to the counseling, which involved speaking up to six times with counselors.

Confronting a Crystal Meth Head
Virginia Heffernan, New York Times- 8/10/2007

Those of us who love A&E’s sick documentary series “Intervention” still become anxious before each new episode. Then, after a hiatus, the wariness tends to turn into something closer to blank terror.

Just when you’re feeling pretty good, in other words, like you don’t even need a new “Intervention,” and could go about your television life in a measured, temperate way, taking it one day at a time and surviving if not quite cold turkey then at least just on the occasional rerun, back it all comes: the new addicts, the gruesome histories, the sores, the rosacea, the needles, the wily liars and then, at last, the catharsis of the confrontation that is the program’s reason for being.

So, it’s back. “I could probably do as much as you could give me,” Coley, a logger and crystal methamphetamine addict, says on tonight’s episode, the first of four new ones. He is extolling the virtues of being incredibly high on speed while one-handedly felling huge trees. “I could just move mountains,” he says.

This is a new one — or so I tell myself each time with “Intervention,” convinced that each macabre particularity makes the fall-and-redemption formula here bearable. And it is new: Coley’s snarling chainsaw is an unusual accessory for an “Intervention” addict. And not only is his character — a deranged American frontiersman, a figure from a horror movie — instantly terrifying, but, as a working-class outdoorsman and a head of household, he also comes from a demographic underrepresented on “Intervention.” (Perhaps the families of these scary men are reticent to intervene, while the parents of heroin-addicted girls are more forthcoming.)

What’s uniquely fascinating about Coley, however, is his bizarre obsession with finding burl in the woods: the swirly cancerous growth on trees that can be used in guitars and gun handles. His quest for burl takes on epic proportions, and both he and his wife are mindful of the burl-speed connection. There’s an unusual poetry in how they discuss it. This is such a far cry from the concerns of other “Intervention” addicts — the money-and-appearance preoccupations of Caylee on next week’s episode are more typical — that even (or especially) a hardened “Intervention” viewer will find it difficult to look away.

Coley’s house and family are lovely, naturally, but he locks himself away in one of the murky corners that viewers of “Intervention” have come to recognize as the addict’s refuge. In Coley’s case it’s a garage stocked with garden tools, flammables and his sacraments: a broken piece of clear plastic on which he flattens out white powder with some kind of credit card. He then heats it up and inhales it. There’s also a dog.

Participants on “Intervention” have evidently consented to appear in a documentary about addiction. (This in itself is astonishing, since so many of them are shown engaged in illegal activities. Is no one prosecuted for using drugs in these documentaries? Do the producers have any culpability for standing by?) They don’t realize that their confederates are planning an ambush with the producers, and a cadre of intervention captains.

There’s a protocol for the intervention: People read letters, and cry and hug, but the goal is to get the addict to consent to go to treatment then and there.

It turns out that Coley’s mother had speed problems of her own, and introduced her son to alcohol at the age of 9. He found her wicked ways thrilling, and was dealing meth with her by the time he was in high school and quickly went to prison. (Caylee of next week’s installment also shares addictive behavior with her mother, as well as a grim mutual obsession.) During a period of reform — after a spell in jail — Coley met his wife, and they had three children; he’s had some treatment for addiction in the past but evidently suffered setbacks after his mother died of an overdose.

Coley’s experience with drug treatment suggests that he’ll be amenable to the intervention, but I’d never spoil the suspense and give away whether he consents to mend his ways — or walks out. Addicts on “Intervention” do walk out. The feeling of betrayal can be extremely potent.

“I really don’t know where I’m going, but I’ve been there before,” Coley says, at one point, on his way to seek burl. As the episode rolls on, and tension mounts, Coley becomes among the most endearing of the “Intervention” addicts to date. This twistedly compelling series has clearly not lost its appeal. Its compassion for addicts and their families — and for the thorny idiosyncrasies of their plights — redeems its seamier side.

And then there are the characters, like Coley. As a man who clearly loves both his mother and wife to distraction, he’s also been on drugs for so long that he has a hard time finding the part of his brain that’s unaffected by them. Possibly as a consequence, he tends to think and talk with a kind of mandarin detachment, though he’s slightly abashed about lapsing into what he calls riddles. At times he turns existential.

“I’m not being, like, weird or anything, but that’s not me in that camera right there,” he says at some point. You believe him.

Army Starts New Psychiatric Program
Robert Weller, Associated Press- 8/10/2007

DENVER -- The Army has launched a nationwide program to teach soldiers and their families how to identify signs of possible psychiatric injuries suffered in the war on terrorism that may have gone unnoticed.

The Army is responding to widespread reports that soldiers returning from Iraq and Afghanistan with mild brain damage and post-traumatic stress disorder were treated as malingerers or unfairly dismissed from the service.

The training program, called "chain-teaching," was implemented last week at the Pentagon and is intended to reach all active-duty soldiers and reservists within 90 days.

Fort Carson officials plan to discuss the program with media Tuesday, base spokesman Capt. Gregory Dorman said.

The military has acknowledged facing an unprecedented problem, and said that even with the best treatment and preparation, some soldiers will suffer lifelong mental injuries.

"At no time in our military history have soldiers or Marines been required to serve on the front line in any war for a period of 6-7 months, let alone a year, without a significant break in order to recover from the physical, psychological, and emotional demands that ensue from combat," a military report released in May said.

Previously, the draft had guaranteed commanders had replacements for those who had spent considerable time in combat.

Capt. Scot Tebo, surgeon for the 4th Infantry Division's 3rd Brigade Combat Team, said the goal is to identify soldiers with problems as soon as possible so treatment can begin.

"It is important to remember, although you may not be struggling, your battle buddy may be," Tebo told the Fort Carson Mountaineer.

The program will teach soldiers and their families to spot possible indications of post traumatic stress disorder, brain damage and other injuries resulting from service in combat. Additional resources will be available online.

“I guess — ” Clem began.

“I don’t hear the difference in the question.” More sharp chips; Marie would not be denied. Seated next to her husband, she had turned to confront him, though, as usual, she was holding a large pillow in her lap — between her and him, between her and the rest of the group. Light dappled the walls of the Jersey Shore office, reflected sun off the bay three stories below.

“I guess I’ve tried different ways, and nothing seems to . . . to . . . ,” said Clem, who stutters when he’s challenged, or trying to plead his case. He is the personification of mild: fit and trim, with cornflower blue eyes. “It doesn’t seem like you hear me no matter how I say it.” Later, he’ll say, even more plaintively: “It sounds like you want me to initiate sex, but it’s just hard to because the answer is always no, or ‘O.K.,’ and that just doesn’t turn me on. It really takes all the wind out of my sails to know that you’re only saying yes to appease me.”

This was the fourth session of a yearlong couples-therapy group led by a Philadelphia psychologist named Judith Coché, and it had already been established that among Clem’s major reasons for being here was the sexlessness of his marriage (once a month at best, though the couple would disagree about the frequency in a perversely predictable way: Clem, who missed it most, believed he’d had it the least, and vice versa). Resentment and anger, meanwhile, seeped from his wife, the mother of their two teenage daughters, which sounds like the oldest story of marital disenchantment in the book — and, to some extent, it is. But what I discovered sitting in on this couples group for a year is that every family is unhappy in its own way — its own peculiar, layered, internally contradictory, often surprising way.

Who would submit to a couples group? On the surface, a rather unprepossessing group of five men and five women, all of them intelligent, ranging in age from their mid-30s to early 60s, several with high-powered or high-status jobs, the rest working in retail and white-collar middle management. A few had been in some kind of therapy for years, but others were fairly new to the enterprise. Only one couple, Marie and Clem, began in obviously dire straits; another pair, often as not, were savoring the improvements they’d already seen in their marriage. This was their second year in the group, as it was for Marie and Clem; while the couples “contract” to attend a year’s worth of sessions, they may sign up again at the end of that time. (I was allowed to attend the group, which started in May 2006 and met for six hours one day a month and for a weekend twice during the year, provided that I used only the middle names or nicknames of anyone I wrote about.)

Coché’s groups are made up of clients from her conventional individual- and couples-therapy practice as well as referrals from colleagues. Groups are particularly helpful, she told me, for people who are rigid or keenly defensive, since the clamor of different voices is harder to dismiss than a single, ever-so-reasonable therapist. Couples in which one spouse can barely speak up for him- or herself are also prime candidates, she said: the meeker half will find a “subgroup” within the larger group to take his or her part. She excludes people who are severely mentally ill, are of limited intelligence or have some impediment to showing up every month. For those who are willing (and can afford the $4,000-$6,000 sliding fee), Coché maintains that being in a group is the swiftest, most potent way to affect marital “transformation.” And the potential for change is, of course, why I wanted to spend a year with a group. How does marriage work to tear people down — leaving them feeling bitter or diminished, dulled or lost — and if that process can be interrupted, if a therapist and a group of other couples can lift spouses out of the muck of their own making, what does it look like?

Like the vast majority of therapists in the United States, Coché describes her therapeutic orientation as “eclectic.” What’s most prominent in her approach, however, is the influence of existentialist philosophy, a theoretical framework that assumes people are, above all, driven to find meaning in their lives. She also thinks “systemically,” such that, among other things, she’s attuned to how couples collude to create their own misery, often to insist upon it — because of some unseen comfort the ostensible misery provides. As the late psychoanalyst Stephen Mitchell observed in “Can Love Last? The Fate of Romance Over Time,” his 2002 book: “When patients complain of dead and lifeless marriages, it is often possible to show them how precious the deadness is to them.”

Coché, who has been running couples groups since the late 1980s in Philadelphia and Stone Harbor, N.J., where she has a second home, is a tall 64-year-old brunette with auburn highlights, a raspy laugh and a taste in clothes that is a cross between urban elegance and ’70s earth mother. When Coché conducts the group — and “conducts” is her metaphor; she and her husband have season tickets to the Philadelphia Orchestra, and she says they always sit at the back of the stage behind the players, so she can watch the maestro work — she is commanding, almost showily confident. “Creating a sense of performance, it’s really inspiring to people,” she says. “It gives them something to hold on to when everything is falling apart.” She displays so little vulnerability in the group, in fact, that traces of it are oddly riveting — like when she folds her 5-foot-10-inch frame into one of the modern leather chairs in her Philadelphia office and her awkward-adolescent self pops into view: one long leg splayed here, another there, her arms hanging loosey-goosey over the sides, fingertips grazing the floor. Or when she injured her hand in a boating accident and came to the group with a large white bandage wrapped around her authoritative index finger, chips in her wine-colored nail polish.

Her own life was badly shaken 16 years ago, when her first husband, Erich Coché, a Dutch-born psychologist who had a national reputation for research in group therapy for the mentally ill, died at the age of 49, less than a year after a melanoma was diagnosed. Judith was besotted with him, she told me one day, from the moment they met. “Will you have a hamburger?” he asked, accosting her on the boardwalk in Atlantic City, where they were both attending a professional conference more than 40 years ago. (A colleague had told him this was the best way to ask an American girl out on a date.) Only 23 years old, Judith was drawn to his European cosmopolitanism, his intellect, how different he was from anyone else she knew. “On our second date, we went to the zoo, and then we spent the next year talking about how it was impossible to get married,” she said. “How could a Main Line only child of Jewish parents, some of whose family had been killed in the Holocaust, marry a Dutch-German?”

Their careers were intertwined from the start — she had her first published article, about a girl she treated in a children’s therapy group in Philadelphia who chronically soiled herself, translated into German, which Coché likes to say she learned “to talk to her mother-in-law.” She and Erich wrote an academic book together about couples groups and led the group together until the very end of his life, when the cancer left him weak and muddled. He’s still a touchstone in her professional life — “according to Erich Coché . . . ,” she’ll say to the group — but she remarried in 1994, to a C.E.O. in scientific publishing who is now retired. She and Erich had one child, a daughter, Juliette, a wife and mother herself who has recently joined the family business. She is scheduled to lead the 2007-2008 couples group with her mother, in addition to serving as a chief resident in psychiatry at the University of Pennsylvania.

Professional-led groups for people with discrete emotional or physical conditions — Coché has run them for overweight adults and learning-disabled adolescents — have become ubiquitous in the last three decades. More recently, couples education, especially the premarital sort, has taken off inside and outside of religious groups, spurred in part by federal financing from the Bush administration. But the type of ongoing experiential group Coché runs, which is heavily dependent on mining the interactions among the members in the so-called here and now (“Sitting here for six hours you just know what it’s like to be married to him,” Coché muttered to me once, out of earshot of the offending spouse), aren’t terribly common.

When Coché lists the virtues of the group over other forms of therapy, she cites the “Greek chorus” effect, a term that captures how members begin to harass one another, if politely, about the habits corroding their marriages. “In a group, there’s an experience of being held accountable for one’s own behavior,” Coché told me, adding that it’s more powerful to be called out — or cared for — by a civilian than by a professional. “I’m a paid consultant. I’m a nonperson.” Other benefits she cites are the often-silent products of group dynamics. No matter how ultimately prosaic their woes, members are startled to see reflections of themselves in the other marriages — My God, I do that, too — and if one person musters the strength or resolve to make a change, somebody else may consciously or unconsciously follow. The principle of isomorphism also comes into play, she said, meaning that as people forge intimate connections within the group, the enriching encounter in that system may spread to the other system: the marriage.

Finally, Coché extols the “community” in which the group envelops couples. As panoramically documented by historians like Stephanie Coontz, marriage used to exist in a web of extended-family obligations. For the upper classes, its purpose was to magnify wealth and power; for the lower, to choose a spouse who could contribute sweat or material goods to the small business that was each household. Gradually, with industrialization and the movement of jobs outside the home, love replaced communal economic imperatives as the glue between husbands and wives, striking two blows to the institution. First, romantic love isn’t known for its long-lasting adhesive properties; and second, no one is as deeply invested in a marriage as the two people in it.

The group is something of an answer to the latter problem, Coché says — the modern equivalent perhaps of the village that Michael Vincent Miller, a psychologist, depicts when lamenting the isolation of modern couples in his 1995 book, “Intimate Terrorism.” What would it be like, he writes, “if as in the Puritan villages of old, representatives from the larger community were to step in, calm the two down, stress the larger social importance of their well-being and offer support and help by redirecting the couple’s energies away from mutilating each other toward something more cooperative.”

In addition to Marie and Clem and the couple whose revived marriage was either inspiration or reproach (depending on how you looked at it), the villagers circa 2007 included another husband and wife who were group veterans and two couples who were participating for the first time. The two new couples were both in their mid- to late 30s, and each had been married about a year: one pair was there because they’d each been divorced before and feared replicating the ugliness that doomed their first marriages; the other began the group insisting that everything was copacetic between them but would eventually find that their relationship had dismaying parallels to Marie and Clem’s. “If in 20 years my husband feels like” Clem does, the young wife moaned to me, referring to how controlling and demanding her own husband perceived her to be, “that would be horrible for me. If that’s where we’re headed. . . . ”

Perhaps because of what they shared, the young wife was the first member of the group to plainly criticize what she saw happening between Marie and Clem, although not until midway through the year. “As a person who’s known you for six months,” she told them wearily, and a little tearily, “it’s brutal listening to you.” She was intervening in another of Marie and Clem’s repetitive dialogues about sex, explaining to the couple that the tension between them reminded her of her childhood. “My parents are still married, so it’s not that it can’t work out — ”

“Remarried,” Coché corrected. The young wife had seen Coché when her parents were divorcing; a decade later, she contacted Coché again, this time about her own marriage.

“Remarried,” the young wife parrotted, “but now my parents are, like, actually happy and able to talk things out and joke about their differences. But it’s hard.”

An extremely self-assured Ivy League M.B.A., she was what Marie might have been had Marie been well loved as a girl, her precociousness encouraged and nurtured. Marie grew up as the bookish only daughter in a household of small-town men: two older brothers and a father who, according to her and Clem, can be best described as bullies — physically intimidating, crude and derisive of the opposite sex. She graduated with honors from a small college (which was where she met Clem, who dropped out during his sophomore year) and went on to excel in her career as a medical administrator. But the job didn’t offer the wide vistas, the intellectual challenges, that Marie relished, not to mention that her exacting standards didn’t always make her popular at work. She tried to compensate with her own voracious reading — she liked nothing better than to hole up in her bedroom with her Civil War magazines and volumes of philosophy and history — but Marie had grown increasingly disgruntled and unfulfilled professionally, as well as in her marriage. Clem loved to boat and fish and body-surf but wasn’t much into books or ideas.

Marie told me she felt a glimmer of a kinship with the young wife — they were both the uncontested captains of their marital ships, though Marie was far more brittle — and now in the sixth session the young wife was imploring Marie to recognize that the love between her and Clem was more important than the laying out of their respective “positions.”

The young wife’s choice of words was deliberate; she was jabbing at how Marie talked as much like a State Department bureaucrat as a wife, how she repeatedly invoked transparent “negotiation” as the cure for what ailed her marriage. Marie clung to this frequently cramped and cold way of expressing herself, it seemed, because her major complaint about Clem was that he obdurately stuck to pleasantries, leaving her wrapped in a lonely gauze, at best, and at worst bewildered by his sudden claims of injury at some crime she hadn’t known she’d perpetrated. Her fervent desire was for Clem to tell her exactly where he stood.

So as the couple again hashed out their differences about sexual frequency, it seemed less about the substance of the matter for Marie — less about a wish that her husband seduce her rather than offer croutons — and more like a set-piece for her to demonstrate to him that he never talked straight to her. “Some of it is getting to the point where we can compromise,” Marie told Clem and the group. “If he’d say something like, ‘Right now I’m lonely and need your company,’ it would give me the opportunity to put everything down and go with you, to show you how much you mean to me.”

“Why do you need to hear him sound like he genuinely wants and desires you?” Coché asked, trying to nudge things away from the realm of negotiation and instead get the couple to acknowledge that neither was adept at expressing tenderness.

“It lets me know his position, first of all,” Marie said — so much for Coché’s nudging. “And it’s a reminder to me that this may not be the natural way for me to go, but because it’s Clem asking, I need to go that way.”

“Could it be because you love him?” Coché pressed.

“Yes, and, um . . . ,” mumbled Marie, for once at a loss for words.

“It’s important to say that part,” Coché said.

“O.K., because I would love you,” Marie said, and then quickly, as if wanting to correct her cringe-worthy use of the conditional before Coché could, “because I do love you.”

At moments like these, the love between Marie and Clem seemed aspirational rather than actual. Coché’s questioning underlined that, but it was the couple who’d both been married before who pushed the matter to what seemed like its logical conclusion. “I guess it just kind of brings back memories of my first marriage,” the wife said to Marie and Clem in her soft, melodic voice. “And the key thing on my mind is: Do either of you really see a big future?”

Clem’s eyes flitted around the room, while Marie kept her gaze glued to her lap. Her long ponytail, which she wore on the side in a rubber band, blended in with the furry pillow she was stroking, so that her hair almost seemed to grow out of it.

The previously divorced husband broke the silence. He’d been having flashbacks of his first marriage, too, of having to “beg to go to the bedroom,” of his ex not saying hello to him if she was busy when he arrived home from work. “I agree. Should you two just say, ‘You know what, we should move on’?”

Coché had mentioned to me that near the end of last year’s group Clem told Marie he wanted a divorce. When I asked her why he changed his mind, she replied, chuckling fondly, Marie “told him she didn’t want to get divorced, so he said O.K.” That perfectly captured the dynamic between them in the group, but when Coché reminded Clem of his divorce threat and asked him to explain why he backed off, I was still taken aback at how baldly he stated it: Marie “was upset, and she wanted to stay together, and I guess I thought, If she wants to stay together, I’ll, I’ll uh, I’ll give it go.”

What every married person who has considered couples therapy wants to know is whether it works. But while there is a fair amount of research on the question, it isn’t particularly illuminating. Two years after ending therapy, studies suggest, about 70 percent of couples report being more satisfied with their marriages, citing lowered levels of conflict, for example, and better communication skills. Less encouraging, however, is the finding that the reforms don’t often catapult couples into the realm of the happily married, according to Jay Lebow, a psychologist at the Family Institute at Northwestern University who specializes in interpreting studies in the field.

What studies — pioneered by John Gottman, a psychologist and emeritus professor at the University of Washington — have rather convincingly shown are the marital patterns likely to result in divorce. In his famous “love lab,” the Family Research Laboratory, Gottman observed more than 3,000 couples during three decades of research, analyzing their discourse, including arguments, and recording their physiological responses. What he concluded is that it wasn’t whether people fought — 69 percent of his subjects never resolved their conflicts — but how they fought. The relatively happy couples did not escalate disagreements; they broke tension with jokes and distraction and made “repairs” after arguments. When wives raised issues gently, for example, neither partner’s heart rate exceeded 95 beats per minute and the ratio of positive to negative comments during a fight was an amazing five to one.

But how do couples become what Gottman calls “masters of marriage,” the most contentedly married couples? He and his colleagues are collecting data on a type of marriage counseling they designed based on the insights from the love lab, but the consensus of the research to date is that no single therapeutic model — for individuals or couples — outshines any other. Investigators have repeatedly tried to single out specific “therapeutic factors” that can distinguish good therapy from bad, and the only unequivocal winner is what’s termed a “positive therapeutic alliance,” meaning the client feels that the therapist exhibits qualities like empathy and support.

Jay Efran, a psychologist and emeritus professor at Temple University who surveyed the last 25 years’ worth of trends in therapy in an ambitious recent article in Psychotherapy Networker, has another idea about what makes for an estimable therapist. He suggests that therapy boils down to a facility for conversation and therefore is a creative and contingent act that does not lend itself to formulas. “The profession has gotten itself into a bind,” he told me recently, “because it wants to be seen as a science and it wants to collect money, and it has made this category mistake of thinking it provides treatments for diseases and not just conversation or community or human contact or offering new slants on life.”

Efran’s notion is an appealing way to conceive of Coché’s talent. Because while she has read and trained extensively in several schools of therapy, she was at her least inspiring when expounding for the group on big-picture theories of “coupling.” She thrived in the moment — interceding in or interpreting the to and fro between a husband and wife, or pulling out unexpected common threads in the stories the couples were telling, giving the assemblage a whiff of fresh perspective.

Coché has a provocateur’s bent, a spiritedness that is missing from what Efran calls the “lovey-dovey pablum” that usually characterizes the positive therapeutic alliance. And she knows this about herself: she once took a picture from her shelf that shows her grinning beneath a mass of black curls, her daughter’s white Balinese cat draped across her shoulders: “I keep this here because this is what the job is like to me. I look a little mischievous, like I’m having fun.” One of her basic tasks, she told me, is “titrating anxiety,” challenging people enough so that they’ll feel the pressure to change but not so much as to send them spinning off in alarm or confusion. As she put it another time: “Causing the right amount of trouble is an art form.”

For the afternoon of the first weekend-long session last October, Coché invited a Pilates instructor to take the couples to her nearby studio and teach them some movement exercises, on the theory that much of the communication between couples is nonverbal. That this would be arduous for Marie was not lost on Coché. “She shrinks from physicality, so we prescribe it,” she said, “and help her with her reaction when it occurs.”

It occurred. About 45 minutes into the class, Marie fled. She could be heard blowing her nose outside the room — before leaving the premises entirely, not to return for the rest of the day. When she left, Coché hurried out after her to try to help, but Marie rebuffed her.

Back in Coché’s office afterward, a jittery Clem told the group that Marie was infuriated because he’d broken a “no teasing“ edict she’d laid down before they began. He did “the bump” with her during an exercise in which the couples were asked to lean into each other in various configurations.

That instigated a chorus of criticism — what’s the big deal, what’s wrong with her — until Coché stopped it: “Now, before we get into whose fault it is, it’s totally unimportant. If these people want to be married to other people, then they can decide whose fault it was.”

It echoed something she said to Marie and Clem in a previous session, when he objected during a discussion of their sex life that it didn’t seem “normal or natural” to ask his wife to sleep with him in the way that Marie wanted him to. “It’s not a question of normal or natural,” Coché said. “It’s a question of healing and repairing a degree of damage that is so deep and so long-term that there’s going to be a process of building that is going to feel very awkward.” The damage to which she referred was both the years of alienation between them and the impact of Marie’s girlhood. (Marie was careful to say that while her father may have punched her on the arm to show affection, or smothered her in hugs until she cried and begged to be let go, no one in her family sexually abused her; she knew her sensitivity to touch aroused that suspicion.)

The next day, Marie arrived looking glassy-eyed and grim and announced, “I just sort of wanna get through the day.” Before the group began, while people were filtering in and picking at the breakfast of bagels and coffee Coché had laid out, the therapist took Marie aside to ask how she was doing. “I’m fine,” Marie said. Now she sat on the couch, eyes closed, holding her head in one hand, petting Coché’s Portuguese water dog with the other. Just before lunch Coché asked if there was any way the group could help. Barely looking up, Marie said that the only reason she’d returned was because of the “contract,” prompting Coché to ask why she told her she was “fine” before the group started.

“Because I wanted you to drop the situation immediately,” Marie said.

“Why?”

“Because I don’t want to discuss it.”

“Are you angry with me? Did I push too hard yesterday?”

“When I say I’m fine, that means just drop the subject,” Marie spat.

“Could you do me a favor,” Coché said, as calm and collected as if she were asking Marie for the time, “and instead of saying you’re fine, could you say, ‘I need to be by myself’?” Coché wanted Marie to see that when she was angry — at her husband or anybody else — she’d be better off stating it rather than withdrawing behind a froth of fake assurances.

“Um, no,” Marie said. “I find that when I say that the response is the exact opposite.”

“I see,” Coché said evenly. “So the only way you can get me off your back is to say you’re fine when you’re not.”

“I’ve found that’s the only thing that works with you, and with many other people,” Marie said, seemingly referring to the ghosts of her father and brothers that Coché believed were lurking in the room.

After lunch, Marie was again Topic A, prompted by one of the veteran husbands, who was the closest thing the group had to a traditional paternal figure. Earlier in the year, when Coché instructed each member to choose a few people to act out a childhood scene between his or her parents, everyone kept picking this man to play the volcanic father, until he had to stop. He was visibly shaken by having to thunder at one cowering child after another; while he and his wife had turned the corner in their marriage, they’d initially come to Coché because of the increasingly volatile arguments he was having with his middle son.

“Maybe you can help me with this,” he said now to Coché, “because I’m not feeling good about” Marie. He couldn’t explain his reaction to her behavior much beyond that, which was typical for him, and Coché intervened. This wasn’t just about Marie, she said. This was an opportunity for people to consider how they cope in their own lives with silent, smoldering presences who swat them back by insisting everything is “fine.”

The group had plenty to say, though nobody directly condemned Marie, despite palpable frustration at how she kept repeating “fine means fine.” The young wife who feared her husband might turn into Clem went so far as to thank her — and sounded as if she meant it — for helping her to realize how pained she was when she recently called home and her father picked up the phone and passed it wordlessly to her mother. (“He loves you even if he doesn’t always show it,” her mother stammered.) Her father had always retreated into silence when he didn’t know how to solve her problems, she said, and while she didn’t know exactly why he was upset this time, she thought that perhaps it was because, as she’d previously informed the group, she’d had a miscarriage and her father wanted her to wait longer before trying to become pregnant again.

As the colloquy ground on, Marie’s eyes just got narrower, her protestations more verbose, until Coché offered that maybe, just maybe, Marie was “transferring” onto the group members, transforming them into siblings, such that she could never be persuaded that the people surrounding her here 30 years later weren’t merely attacking her.

“O.K.,” Marie said, simply. It was as if she’d awakened from a nasty fugue. In the next group, she was practically cheerful — was it because she and Clem had had a good month, as they both said, or because Marie’s considerable pride had been wounded by the Pilates debacle and she wanted the group to know that she was still a force to be reckoned with — that she wasn’t going to stay in the role of traumatized victim? The respite was brief, however. Veiled belligerence toward Coché and indifference toward her fellow group members — many of whose names she told me near the end of the group she could barely recall — would continue to emanate from Marie. And every so often she’d say something that overtly betrayed her attitude, like when Coché asked whether she’d help the young wife with a difficulty the two had in common. Marie paused for what seemed like forever, before saying: If by help you mean letting her listen “as I explore this issue,” fine, I’ll help — but don’t expect anything more from me.

Still, Coché believed that the group had Marie to thank for amping up the level of intensity and frankness in the room. The group was a little low on the “affect side,” she told me, meaning for quite a while people seemed stuck in the superficial “joining stage,” unwilling to feel, never mind express, much emotion. Marie got their “juices flowing,” as one of the men put it, if only because she stoked their ire. For instance, during the Pilates weekend that I came to regard as “Marie’s Insurrection: Part I,” the young wife and her husband had their first honest, heartfelt exchange about how divisive and frightening it had been to suffer a miscarriage. Until that point, the woman had alluded to the loss only in abstracted psychobabble: “I’ve been trying to honor the missing.” Or: “I feel very healthy about not worrying about not being sad.”

As locked in her ways as Marie could seem in the group, she and Clem reported an upswing in their marriage during the second half of the year. Several times, Clem said he was realizing that he’d contributed to their knot of unhappiness by repressing his own anger and dissatisfaction and was trying to be more vocal and assertive. The group noted that his posture seemed better; he’d stopped slumping on the couch like a teenager being scolded by his mother. Marie, who went for years believing she didn’t have “the right” to expect anything from a man other than what he decided to bestow, was asking for what she wanted from Clem and doing so more considerately, they both agreed. Her so-called submission didn’t work, anyway, she acknowledged, because her fury just festered (and was hardly hidden). The couple were having sex a little more, Clem said, and once he went so far as to say he felt “lucky” to be married to Marie.

But the progress was fitful, and the group observed how defeating it would feel to live with someone whose main weapon was to become more passive, more (spitefully) a good guy. Clem and Marie got into a protracted debate about why he had “disregarded” her and taken a basket of clothes to the basement, when the previous night she unambiguously stated that she wanted to do the laundry herself. For at least an hour, the group batted around how Marie could have made the request more gracefully — with Clem chiming in to say he was just trying to help out.

Finally, rather suddenly, Clem conceded that in this instance Marie had made her preference known civilly, that she had thanked him for taking sole responsibility for the job while she was taking a class related to her work. He’d picked up the basket to “poke back” at her, because he felt demeaned by her disdain toward his laundering methods. Moreover, he knew he was taking the same put-upon, saintly role as his father, who was constantly hectored by his mother, and then a little later, he blurted: “I think some of it might even stem from a week ago when you said I didn’t work that hard in the group, and . . . and that really insulted me.” Which he hadn’t told her at the time.

Marie concurred that her comment sounded insulting, in retrospect, but she was despairing over how to get her point across, how to be heard by Clem. Eventually she started to sob, which she’d never done.

“I can’t make things clear enough,” she cried.

“And gentle enough,” Coché added. She — and everyone else in the group — regularly pointed out to Marie how harsh she sounded.

“And, yeah, if I make it more gentle, I’ll dilute it even more.”

“For those of you who are passive,” Coché said, shifting from Clem’s point of view to Marie’s, “who control by withdrawing, this is what it feels like to your partner. This is why they try to boss you around, because they don’t know what else to do.”

Coché later explained to me the dance she was doing with Marie and Clem. On the one hand, she was teaching them the steps that are these days associated with the ur-couples researcher John Gottman: behavioral fixes, like advising Marie to speak more kindly to Clem or suggesting that he ask her to go for walks on the beach. If relatively happy spouses say and do a lot of nice things for each other (creating the “positive sentiment override” that allows them in fraught moments to avoid demonizing the other and instead give the benefit of the doubt), Gottman’s thinking goes, then coach the unhappy ones to do the same.

This may sound obvious, but anyone who has been married for a long time knows that gestures of affection and regard don’t come easily in the domestic fray. Yet when one spouse manages to rise to the occasion, the good will that ensues usually seems of a much greater magnitude than the puny act of kindness that precipitated it. As no less a twisty and penetrating thinker than Adam Phillips, a London psychoanalyst, muses in his 1996 book, “Monogamy”: “What if our strongest wish was to be praised . . . not to be loved or understood or desired? . . . What would our relationships be like? . . . We might find ourselves saying things like: The cruelest thing one can do to one’s partner is to be good at fidelity but bad at celebration. . . . Or it’s not difficult to sustain a relationship but it’s impossible to keep a celebration going. The long applause becomes baffling.”

Coché seems to instinctively grasp the value of wild clapping for one’s spouse. The group could overhear her on the phone calling her husband “my hero” for helping to fix the office plumbing; she bragged about his various accomplishments to me, which could be construed as a bid for reflected glory but was also a way to keep the celebration going. Nonetheless, Coché said, if a couple piles up enough grudges, then building “a culture of appreciation,” as Gottman calls it, can only be one part of the therapist’s repertory.

As time ticked down on the yearlong contract, it sometimes seemed as if the group had been reduced to a battle of wits between Coché and Marie. Which is not to say that the other couples weren’t benefiting. During the Talmudic laundry inquiry, for instance, the young wife’s husband smacked his forehead with his palm. “Oh, for the love of God, I’m doing it too!” he exclaimed, wondering at how intently but unknowingly he’d put his own wife in charge. Like Clem following in the footsteps of his beleaguered father, this husband was recreating his parents’ marriage, he said: his mother constantly ordered his father around, and his father was “one of the most immature, irresponsible people on the planet.”

In the ninth session, anticipating the end of the year, Coché asked everyone to consider whether they planned to continue on in the group, which would culminate in her asking the couples to make recommendations to one another. Before they got that far, however, Marie volunteered that it was over for her. “Not that you aren’t all lovely,” she said, a thin smile on her lips. The group was too slow for her, and she needed to “pursue other avenues,” she said — seemingly individual therapy, though she wasn’t spelling anything out.

Clem, meanwhile, wanted to enlist for a third round; he thought they were doing better. Coché kicked up her Greek chorus, and the group asked Marie in a dozen ways to reconsider: Maybe she was resisting Clem’s new forcefulness? (No.) Maybe the couple was “splitting the ambivalence” — given that the year before, it was Clem who wanted to leave the group and the marriage and Marie who wanted to press on? (Absolutely not.) Maybe her discomfort with what she called the “fluffy, ‘Kumbaya’ ” aspects of the group reflected her discomfort with expressing warmth in her marriage? (No, no, no.) “Don’t you think I’ve considered and reconsidered all these possibilities?” she asked, incensed.

The two young couples had decided to come back for another year — two of the veteran couples were “graduating” — but Marie wasn’t committing to anything. It was “Marie’s Insurrection, Part II,” and she’d never seemed more bitter.

In “Intimate Terrorism,” Michael Vincent Miller theorizes that marriage, like childhood, has developmental stages, the most dangerous of which, following the heady romantic period, can be summed up as: This person, or this union, isn’t at all what I imagined. What can easily happen at this point, he writes, is that because modern marriage is “under so much pressure to provide so many levels of fulfillment,” because “love and sex are so thoroughly . . . bound up with one’s sense of identity as a man, as a woman,” people become consumed with feelings of failure, feelings that are so unbearable that spouses lash out at their partners rather than apprehend their own panic or contribution to the decline.

The core problem, he goes on, is that our culture doesn’t teach us “to fail gracefully or fruitfully.” Instead, “our notion of the comeback is an attempt to recapture original glory.” The husbands and wives who can move beyond terrorizing each other, or avoid doing so in the first place, he speculates, are those who can first acutely experience their profound disappointment in their inevitably changed circumstances: “Unlike jealousy, cruelty, or boredom, disappointment contains secret hints of mutuality. . . . It is not such a long stretch from disappointment to empathy.”

Disappointment — a sort of rueful recognition of the limits of her marriage and compassion toward the people she and Clem once were — was what Marie, almost incredibly, brought to the last two groups (the first by herself, since Clem could not reschedule an out-of-town work trip). Instantly, it was apparent something was different. She was wearing light makeup and was holding peoples’ gazes long enough that you could see she had sparkling hazel eyes. When it was her turn to say what she wanted to address, she said she’d been reading a spectacular book about the Holocaust and recognized that it wasn’t something Clem could relate to. “Clem was one of the first men that I didn’t feel humiliated by, so he really met a need,” Marie said, and you could see the Clem she was conjuring, the sweet Clem tending to the bruised Marie, the Clem who noticeably shored up the other women in the group. (“When I look over I see a bright, young, attractive woman, and you’re gonna do fine,” he told one of them.)

Marie went on: “I felt comfortable with Clem and not judged and found wanting in all aspects. And had I not changed, Clem would have kept meeting that need.” But Marie wasn’t the same damaged creature anymore, she said. “And I desperately want to figure it out so that it feels authentic, at some point in my life, with Clem; but if the feelings aren’t there, I need to figure out how to create them,” or even if she could.

Another of Coché’s techniques is what she calls “seeding.” She floats an idea and then backs away, lets it sit if people aren’t ready to assimilate it. She’d done that a few sessions before when she remarked on what everyone had noticed, which was that one of the veteran couples seemed to “share a great love,” notwithstanding 27 years of marriage and some serious unrest. But what if you don’t have that? Coché asked. Or never had it? Coché bowed her head, her lips pressed together. Can you generate some of the “tsunami quality,” or is that not really attainable or even necessary? “There has to be a way to acknowledge what is and work with what is,” she concluded, saying she didn’t want to take it much further. “There are many, many models of marriage that are viable.”

Now, it seemed, the seed had taken root for Marie, and the group heaped praise on her for the change. “I’ve never heard you speak this fully or with this much caring in your voice,” one of the husbands marveled. Coché added: “What I’m appreciative of is that you sound philosophical and thoughtful,” which, the therapist said, made it much easier for the group to help Marie get wherever it was she wanted to go. Because in essence, Marie was casting about for what her second marriage to the same man might look like: her remarriage to Clem, the metaphorical version of what the young wife said in an earlier session her parents had done.

Marie’s new outlook lent a degree of hope to the proceedings, a bit of sun. What had inspired it? Coché often met individually with group members between sessions, and that month she and Marie got together for several hours. Moved by the therapist’s explication of how alterations in one system can be imperceptibly absorbed by the other, Marie decided to give the group another year. If she could learn to relate to the other members more constructively, Marie told me, maybe she could bring that to her marriage and family in general — and ameliorate the legacy of “hostile dependency” that Coché said she’d imported from childhood.

The extent to which Marie had aggressively, if unintentionally, cast herself as the villain in the group and her marriage was evident in her reply to the compliment about her new demeanor: “Well, Clem comes off as such a great guy that I feel very defensive in the group, because if he’s such a great guy and we’re here, then there has to be a bad guy. I’m the bad guy.”

Remember, Marie, Coché lightly chided, everything is not black and white: “It would be simpler if some of us had white hats and some of us had black hats, but in fact that’s not the way we are.” Marie nodded.

Also, all the time Marie had been coming to the couples group, she’d been grappling with her stale professional life, and her efforts had been rewarded; she’d recently been selected for a special international project. “People have different styles of changing,” Coché told me. “Marie, she’s a bit of a dramatist about it. She has a temper tantrum, fights it off, has a temper tantrum, fights it off. And then she slides through.”

During the 11th session, the one in which Marie opened up, Coché remarked that couples often can “bond within wider ranges” than they believe possible. Perhaps, then, she said to Marie, Clem could become more of an intellectual partner for her than she assumed? “I don’t think it’s in him,” she said, “and in a way, if it were in him, I’d lose Clem.” This was touching, because Marie sounded as if she cherished what was in her husband, but it was also an example, perhaps, of her extreme, black-and-white thinking.

One of Marie’s troubles, the psychoanalyst Stephen Mitchell might have said, is that she seemed hooked on safety. Marriage typically meets our sharply felt needs for security and predictability, he argues, but in those relationships that last well, people take the leap of believing that they actually don’t know exactly who the other person is or what he or she is capable of — the absolute knowingness is a fantasy, anyway — and that there is new terrain to be discovered. So, out of deference to Marie’s fascination with the Civil War, Clem was planning a summer trip to visit some battle sites with her. And maybe, if Marie would dare risk it, Clem could get caught up in the history of the era, too. And maybe, after watching her husband traverse the grassy fields of Antietam, she’d even want to sleep with him, if she could bear him being anything other than dependable old Clem. (Not incidentally, Clem was as enamored of stability as his wife. When I spoke to him outside of the group, he told me one moment of his yearning for Marie to “roll over and kiss” him in bed. The next, he said that she met perhaps his top requirement for a wife: She’d never “stray or look at other men or have an affair. Marie’s true to me, and that’s one of the things I wanted, and that’s what I got.”) One late-spring evening before the final session, I met with Marie and Clem at their home. As we sat on their screened-in front porch watching the light drain out of the sky, I saw how right Stephen Mitchell was, how precious deadness could be. Marie was barefoot, wearing one of what I considered her “group dresses,” a smocked jean jumper with a short-sleeved yellow polo shirt underneath; Clem had on a polo shirt, too, one that matched his blue, blue eyes. They’d invited me to visit them at their lovely mint-green-shingled two-story home, which they’d bought as a falling-down wreck and worked to make livable through the succeeding 20 years, while raising two daughters and working full-time jobs (except for a demoralizing period when Clem had back problems and couldn’t find steady employment).

After all those years of sawing and scrimping, there was this sturdy house with shelves built by Clem, a vase of daisies on the kitchen table and white wicker furniture on the porch. There were the beautiful, smart girls, one of whom darted through the kitchen in shorts and headphones, headed out for a run. There was the garden that Clem showed me — “Marie’s pride and joy” — and the shiny used Mercedes that Marie said Clem had “always wanted” and recently managed to buy. There was the one thing that had always been good in their marriage, they said, as we sat there drinking Coors from frosty mugs, as the seagulls squawked and the dusk turned to darkness: No matter what, they could count on each other for advice and support when either was battered by the outside world.

Would anything truly and irrevocably change for the better between Marie and Clem? Maybe. They both still said that they wanted it, and Coché would later tell me she was thrilled with the strides that they were continuing to make in the new group. But if nothing much changed, they’d still have this house, those girls, the way they cracked up at the same old family stories, her memory of how handsome he looked when she first laid eyes on him in a crowded lecture hall, his of the lingering kiss they shared on her 19th birthday, of the single rose he’d given her. They’d have this house, those girls and the memory of how they’d once been each other’s best or only answer.