1. The Patient with Marital Problems A Patient-Centered, Evidence-Based Diagnostic and Treatment Process 1,2,3 A Presentation for SOMC Medical Education Kendall L. Stewart, M.D. September 19, 2008 1 My aim is to offer practical insights you can put to use in your professional life. 2 Please let me know whether I succeeded on your evaluation forms. 3 Please try to answer these questions before you look at my answers; this is how real-life medicine works.

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

3. What common problems bring people to marital therapy? Infidelity 1,2 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 1 A man decided to tell his wife about an affair 40 years earlier. 2 For both the affair and the confession, selfishness is the usual motivation.

4. Which professionals provide marriage counseling? Ministers 1,2 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 1 Whatever your own attitudes about religion, remember that your patients will put a lot of stock in what these people say. 2 A patient came in doubly-depressed because of what a television evangelist said.

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

6. What are some of the barriers to effective marital therapy? Unwillingness to compromise Unrealistic expectations Lack of self discipline Unwillingness to clarify expectations 1,2 (Money is not a barrier.) 1 People’s expectations—and their spouse’s reaction to them, can be surprising. 2 A 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

7. 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 therapy 1,2 To prepare each partner for the coming process To elicit renewed (informed) commitment to the marriage 1 Clandestine affairs are the most common contraindications. 2 It’s important to realize that most people who have affairs do not want a divorce. They want both.

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

9. What are some of the goals of the initial couples session? Arrangement of a safe environment Expectation of forthrightness and civility 1 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 1 The ability to disagree agreeably is fairly rare. Just think of the people you know who can do it.

10. 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 issues 1 To practice individual accountability To predict and manage the reemergence of old patterns To encourage more reasonable expectations To create the foundation for marital maintenance 1 I now have patients who have seen me rarely for more than 20 years when a difficult issues arises.

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

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

13. Marriage Counseling A 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.

14. 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,” 2000 1 Please visit www.KendallLStewartMD.com to download related White Papers and presentations.

15. 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. 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. http://profreg.medscape.com/px/newsletter.do Subscribe to Evidence-Based Mental Health at http://ebmh.bmj.com/. 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/.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/. http://www.medicine.uiowa.edu/ICMH/evidence/ 1 Please visit www.KendallLStewartMD.com to download related White Papers and presentations.

16. How can you contact me? 1 Kendall L. Stewart, M.D. VPMA and Chief Medical Officer Southern Ohio Medical Center President & CEO The SOMC Medical Care Foundation, Inc. 1805 27th Street Waller Building Suite B01 Portsmouth, Ohio 45662 740.356.8153 StewartK@somc.org KendallLStewartMD@yahoo.com www.somc.org www.KendallLStewartMD.com 1 All speaking and consultation fees benefit the SOMC Endowment Fund.

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