The Patient The Patient with Marital with Marital

ProblemsProblemsA Patient-Centered, Evidence-Based A Patient-Centered, Evidence-Based

Diagnostic and Treatment Diagnostic and Treatment ProcessProcess1,2,31,2,3

A Presentation for SOMC Medical A Presentation for SOMC Medical EducationEducation

Kendall L. Stewart, M.D.Kendall L. Stewart, M.D.September 19, 2008September 19, 2008

1My aim is to offer practical insights you can put to use in your professional life.2Please let me know whether I succeeded on your evaluation forms.3Please try to answer these questions before you look at my answers; this is how real-life medicine works.

Why is this important?

• Many of your patients will struggle with troubled marriages.

• Some will speak directly of their unhappiness.

• Many more will convert their distress into somatic complaints and ask you to fix them.

• A few patients will accept a referral to a marriage counselor.

• Some of those will actually benefit.1

• You will want to select good candidates for referral.

• You will need to evaluate your consultants.

• You may want to incorporate what you learn into your own marriage.

• After mastering the information in this presentation, you will be able to identify– Three types of marital

problems that patients present to physicians,

– Three different professionals who provide marriage counseling,

– Three significant steps in effective marriage counseling,

– Three common barriers to successful marriage counseling, and

– Three possible outcomes2,3

1A good number of my patients with marital problems see me as their last resort.2Bear in mind, marital turmoil can be deadly.3As he lay dying, a man decided to confess his long history of infidelity.

What common problems bring people to marital therapy?

• Infidelity1,2

• Impending divorce• Chronic frustration and

resentment• Conflicting values• Destructive conflict• Sexual dysfunction• Abusive behavior• Unrealistic expectations• Disagreements about

money• Perceptions of being

trapped in miserable relationship

1A man decided to tell his wife about an affair 40 years earlier. 2For both the affair and the confession, selfishness is the usual motivation.

Which professionals provide marriage counseling?

• Ministers1,2

• Social Workers• Psychologists• Advanced practice

nurses• Psychiatrists (rarely)• Friends, neighbors and

family members• Television evangelists• Movie stars• Self-help authors• Talk show hosts• An so on

1Whatever your own attitudes about religion, remember that your patients will put a lot of stock inwhat these people say. 2A patient came in doubly-depressed because of what a television evangelist said.

What are some of the steps in effective marriage counseling?

• Careful selection• Preparation• Individual interviews• Preparation of careful

pro and con lists• Mutual confrontation• Couples sessions• Weekly “business

meetings”• Changed behavior• More realistic

expectations1,2,3

1The most common marital mistake is expecting your spouse to change.2This leads to chronic resentment and periodic eruptions of volcanic anger.3My wife is habitually late; When I realized that would never change, I focused on my reaction. Tim’s match.

What are some of the barriers to effective marital therapy?

• Unwillingness to compromise

• Unrealistic expectations

• Lack of self discipline

• Unwillingness to clarify expectations1,2

• (Money is not a barrier.)

1People’s expectations—and their spouse’s reaction to them, can be surprising. 2A wife made it clear that she wanted to have sex with other men.

• A lack of commitment

• The existence of competing bonds

• Inadequate motivation

• A decision to divorce

• Incapacitating mental or physical illness

What are some of the goals of individual treatment?• To complete thorough diagnostic

assessments• To elicit individual relationship histories• To assess each spouse’s reasonableness

and degree of motivation• To clarify each spouse’s perceptions and

expectations• To identify any contraindications to

marital therapy1,2

• To prepare each partner for the coming process

• To elicit renewed (informed) commitment to the marriage

1Clandestine affairs are the most common contraindications.2It’s important to realize that most people who have affairs do not want a divorce. They want both.

What must be achieved in the individual pro and con lists?• A comprehensive assessment of the

strengths and weaknesses of the marriage• A forthright statement of perceptions and

expectations• Evidence that each spouse has invested as

much thought and effort in the both their pro and con lists1,2

• Evidence of specific descriptions of behaviors instead of vague judgmental inferences

• Clarity about what behaviors must change right away, which ones should change over time and which behaviors can be tolerated forever

• An acknowledgement of what will be lost if this marriage fails

1A surprising number of couples will drop out at this point. 2The unwillingness to make even a minimal effort to save the marriage is astonishing.

What are some of the goals of the initial couples session?• Arrangement of a safe environment• Expectation of forthrightness and civility1

• Creation of an energizing discomfort• Some individual pleasant and unpleasant

surprises• Evidence of the willingness to place all of

the cards on the table• Active listening accompanied by only

clarifying questions• Selection of one or two minor problems

around which to learn new problem-solving skills

• The comforting realization that the sky is not falling

1The ability to disagree agreeably is fairly rare. Just think of the people you know who can do it.

What are some of the goals of the subsequent couples sessions?• To identify, confront and modify maladaptive

behavior• To develop, hone and cement effective

problem solving skills• To contain poisonous emotion• To identify and prevent distractions• To coach spouses in reinforcing techniques• To raise awareness of spouses’ sensitivities• To practice tabling difficult issues1

• To practice individual accountability• To predict and manage the reemergence of

old patterns• To encourage more reasonable expectations• To create the foundation for marital

maintenance1I now have patients who have seen me rarely for more than 20 years when a difficult issues arises.

What is required for successful weekly business meetings?

• A public place– Limits distractions– Contains emotions– Encourages certain

formality• An agenda

– Requires prior agreement

– Gives notice– Discourages ambushes1,2

– Postpones difficult issues– Encourages reflection

and preparation– Stresses the importance

of taking a position

• A commitment– Emphasizes a regular date– Requires a reordering of

priorities• A product

– Encourages documentation

– Encourages a joint position statement

– Requires the creating of a to-do list

– Creates a history of successful problem solving

• A report– Requires accountability– Promotes recognition

1Ambushes are extremely destructive and unproductive.2I once (foolishly) agreed to be present when a wife told her husband that she was leaving him for hisbest friend who had a bigger penis.

What outcomes can be expected?

• Lifelong marital bliss• A reasonably happy and

satisfying marriage• A civil roommate friendship• A marriage of convenience• Extended longing for what

might have been• Lifelong unhappiness and

resentment• A “nice” divorce• An especially nasty divorce• Another miserable

marriage• Premature death1

1I once urged a woman to discontinue efforts at reconciliation. She declined to follow my advice.

Marriage CounselingA Patient-Centered, Evidence-Based Diagnostic and Therapeutic Process

• Take a careful, individual psychiatric history from me and my spouse.

• Do not proceed if you know our marital therapy is doomed to fail.

• Require each of us to prepare careful pro and con behavioral lists about our marriage.

• Insist they we not discuss these lists with each other until the appointed time in your office.

• Require us to revise out lists until they are suitable foundations for our work together.

• Insist that we focus only on those problems that must change.

• Teach us appropriate problem-solving strategies in our couples sessions.

• Require us to conduct weekly “business meetings” outside your office.– A public place– An agenda– A commitment– A product– A report

• Help us develop more realistic expectation for each other.

Where can you learn more?1

• American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, 2000

• Goldman HH, Review of General Psychiatry, Sixth Edition, July 2008

• Flaherty, AH, and Rost, NS, The Massachusetts Handbook of Neurology, April 2007

• Kaplan HI, Sadock BJ, Synopsis of Psychiatry, Tenth Edition, 2007

• Jacobson JL and Jacobson AM, Psychiatric Secrets, Second Edition, 2001

• Stahl SM, Essential Psychopharmacology: Neuroscientific Basis and Practical Applications, Thrird Edition, March 2008

• Stewart KL, “Dealing With Anxiety: A Practical Approach to Nervous Patients and an Overview of the Objectives in the Anxiety Module in the OUCOM Psychiatry Block,” 20001Please visit www.KendallLStewartMD.com to download related White Papers and presentations.

Where can you find evidence-based information about mental disorders?1

• Explore the site maintained by the organization where evidence-based medicine began at McMaster University, http://hsl.mcmaster.ca/resources/ebpractice.htm.

• Sign up for the Medscape Best Evidence Newsletters in the specialties of your choice at http://profreg.medscape.com/px/newsletter.do.

• Subscribe to Evidence-Based Mental Health at http://ebmh.bmj.com/.

• Search a database at the National Registry of Evidence-Based Programs and Practices maintained by the Substance Abuse and Mental Health Services Administration at http://ebmh.bmj.com/.

• Explore a limited but useful database of mental health practices that have been "blessed" as evidence-based by various academic, administrative and advocacy groups collected by the Iowa Consortium for Mental Health at http://www.medicine.uiowa.edu/ICMH/evidence/. 1Please visit www.KendallLStewartMD.com to download related White Papers and presentations.

How can you contact me?1

Kendall L. Stewart, M.D.Kendall L. Stewart, M.D.VPMA and Chief Medical OfficerVPMA and Chief Medical OfficerSouthern Ohio Medical CenterSouthern Ohio Medical Center

President & CEOPresident & CEOThe SOMC Medical Care Foundation, The SOMC Medical Care Foundation,

Inc.Inc.

1805 27th Street1805 27th StreetWaller BuildingWaller Building

Suite B01Suite B01Portsmouth, Ohio 45662Portsmouth, Ohio 45662

740.356.8153740.356.8153

StewartK@somc.org StewartK@somc.org KendallLStewartMD@yahoo.comKendallLStewartMD@yahoo.com

www.somc.orgwww.somc.orgwww.KendallLStewartMD.comwww.KendallLStewartMD.com 1All speaking and consultation fees benefit the SOMC Endowment Fund.

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