You can stay in a relationship with a mentally ill spouse—and be helpful and supportive—if your partner recognizes the illness and seeks ongoing treatment. In my post “When Your Spouse is Mentally Ill,” I talk about how to know when a spouse is mentally ill, how to talk about it, and what to do. In this post, I want to talk about how to successfully stay engaged with a mentally ill spouse who does not seem to want to get better—i.e., be willing to manage their own illness.
As the spouse of a mentally ill person, you typically have done a lot to help your partner get better, like look for the best doctor, be attentive and concerned, try to make things easier for them, honor their wishes and wants, etc. Sometimes, nothing seems to help, and you find yourself getting annoyed that he/she is not working at this as hard as you are. This is the situation in which a person who is mentally ill does not seem to want to get better. They seem to be “stuck” in their illness.
This “stuckness” seems to yield some benefit to the partner. It is not that they do not “want” to get better. It just does not seem to happen. The technical term for the "benefit" gained is "secondary gain." Most therapists believe that this “stuckness” is not a conscious experience. When people consciously feign an illness, we call it malingering—this is different from unknowingly experiencing a benefit from one’s illness. Here are a few examples of such “benefits.” 
- An ill person who finds work or achieving in life too difficult may use his/her symptoms to avoid working.
- The partner of someone experiencing chronic pain will not pressure the person to engage with them in social events.
- Partners of people who are experiencing an ongoing illness are not willing to leave them.
- A partner gets plenty of attention and concern or protection from a spouse.
What to Do If You Suspect This is Happening
You will not be able to convince your partner that they are experiencing secondary gain. If you think confronting your spouse is a good idea, you are wrong. Remember, he/she is not aware of secondary gain. You must get help to figure this out and identify the so-called “benefits” your spouse might be getting from not getting better.
You will need to find a therapist who has experience in dealing with this difficult situation. I suggest you seek out therapeutic help from a therapist who specializes in what is called solution-focused therapy, systemic therapy, or strategic therapy. Therapists with this expertise typically focus on the present situation, focus on interpersonal aspects of an illness, and have several techniques to deal with resistance to improvement. This professional will help you focus on what you can and cannot do for your spouse. The therapist will also assist you in not becoming impaired In this situation.
Managing One’s Own Illness
One element of being able to maintain a satisfactory relationship with a mentally ill person is that they learn to manage their own illness. This typically means your partner acknowledges their illness and works with a professional to understand and moderate the negative effects of the illness on her/himself and those around them.
One of the difficulties of managing a mental illness is that the illness itself can impair the person’s ability for self-awareness. They do not have the same capacity for insight that you might have about why you act the way you do. They may need ongoing assistance in sorting out the negative consequences of their illness and how to manage it. This is hard work.
A Case of Secondary Gain
In my professional experience, avoiding the onerous task of self-management can be a benefit or secondary gain for a mentally ill person. Here is an example of avoiding self-management as secondary gain in a marital relationship.
Sandy and Tim were married for many years with two grown children. She was a homemaker and he was an accountant. Sandy was diagnosed with bipolar disorder for which she was receiving ongoing treatment from a psychiatrist. She and her husband, Tim, were referred to me for help with their relationship.
Sandy had many angry complaints about Tim, some of which were long-held past perceived injustices. She felt “attacked,” “unappreciated,” and “not respected” by Tim, her children, and other family members and friends. Tim dealt with her angry complaints by being apologetic and compliant, seeking to make her happy. This “attack-avoid” dynamic had put their relationship at risk.
Sandy lacked the ability to engage in self-reflection about her own detrimental actions. The lack of self-awareness meant she could not see how she contributed to the negative interactions she had with others. People don’t always have to have insight into their own issues to change their behaviors. One can change how they act if they can recognize that what they do is harmful to others. This is called “self-management” and does not require insight into what causes an action.
Working with Tim
I worked with Tim on staying engaged with Sandy, supporting her in the effective management of her illness, while also establishing appropriate limits on her angry accusations and grievances so that they could have a meaningful relationship. Establishing these limits encouraged Sandy to manage her negative feelings and thoughts without acting on them—working through them with her own therapist.
There were three major ways in which I worked with Tim to be able to both be helpful to Sandy and maintain his autonomy without having to avoid her. These were:
1. Tim was to respond but not react—i.e., neither defend himself nor argue with Sandy’s accusations. Here are examples of things Tim was to say when she did this:
- "I cannot always do things the way you say I should.”
- “I do not agree with the way you are characterizing me.”
- “I will think about what you are asking of me and get back to you with what I am willing to do."
2. Tim was to reframe (put in a different light) the way Sandy characterized what Tim did. He was to say: “I believe the way you characterize what I did (give example) is not true of me. It may be how you feel about things, but I must do what I think is the right thing to do” when Sandy:
- Said Tim never wants to do things for her.
- Stayed focused on perceived past wrong that he has done.
- Expected Tim to intervene with the children when he does not agree with her complaints about them.
3. Tim was to maintain his autonomy without avoiding Sandy.
- Work with the above tools.
- When he needs time away from the situation, tell Sandy directly he needed time for himself.
Maintaining Your Autonomy with a Mentally Ill Spouse
Maintaining your autonomy and not resorting to self-destructive actions like avoidance or retaliation is important in living with a mentally ill person. It is particularly important when your mentally ill spouse may be deriving some unintentional secondary gain from his/her illness. Maintaining your own autonomy while establishing appropriate limitations on the ill person, when employed under the guidance of a professional, can improve a difficult situation—as it did for Sandy and Tim.
The ill spouse will also need ongoing professional help to do the hard work of self-management. And you must maintain your own work and social life, stay informed about your spouse’s illness, and be sure to seek out personal support from friends and family.
A mentally ill spouse may want to avoid the hard work of managing their own illness.
Avoiding self-management of their mental illness can “benefit” them by allowing them to be less accountable and to not do the hard work it requires.
As a spouse, you must not “feed” into the benefit by adopting a negative coping strategy like avoidance or resistance.
You both will need ongoing work with a professional to maintain a good, workable relationship.