Transcript The Anxiety Disorders Some Practical Questions & Answers

The Patient with
Marital Problems
A Patient-Centered, Evidence-Based
Diagnostic and Treatment Process1,2,3
A Presentation for SOMC Medical Education
Kendall L. Stewart, M.D.
September 19, 2008
1My
aim is to offer practical insights you can put to use in your professional life.
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.
2Please
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.
1A
• 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
good number of my patients with marital problems see me as their last resort.
in mind, marital turmoil can be deadly.
3As he lay dying, a man decided to confess his long history of infidelity.
2Bear
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.
both the affair and the confession, selfishness is the usual motivation.
2For
Which professionals provide marriage
counseling?
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1Whatever
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
your own attitudes about religion, remember that your patients will put a lot of stock in
what 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?
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1The
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
most common marital mistake is expecting your spouse to change.
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.
2This
What are some of the barriers to
effective marital therapy?
• A lack of commitment
• The existence of
competing bonds
• Inadequate
motivation
• A decision to divorce
• Incapacitating mental
or physical illness
1People’s
2A
• Unwillingness to
compromise
• Unrealistic
expectations
• Lack of self discipline
• Unwillingness to
clarify expectations1,2
• (Money is not a
barrier.)
expectations—and their spouse’s reaction to them, can be surprising.
wife made it clear that she wanted to have sex with other men.
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
2It’s
affairs are the most common contraindications.
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.
unwillingness to make even a minimal effort to save the marriage is astonishing.
2The
What are some of the goals of the
initial couples session?
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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 maintenance
1I
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
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Requires prior agreement
Gives notice
Discourages ambushes1,2
Postpones difficult issues
Encourages reflection and
preparation
– Stresses the importance of
taking a position
1Ambushes
• 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
are extremely destructive and unproductive.
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.
2I
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 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 problemsolving strategies in our couples
sessions.
• Require us to conduct weekly
“business meetings” outside
your office.
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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
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1Please
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
visit www.KendallLStewartMD.com to download related White Papers and presentations.
Where can you find evidence-based
information about mental disorders?1
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1Please
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/.
visit www.KendallLStewartMD.com to download related White Papers and presentations.
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
[email protected]
[email protected]
www.somc.org
www.KendallLStewartMD.com
1All
speaking and consultation fees benefit the SOMC Endowment Fund.
Are there other questions?
www.somc.org
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