Save Your Marriage

Save The Marriage

Lee Baucom, Ph. D. shows couples with marriage troubles a new way to save their marriage that is far more effective than any marriage counselor in this marriage course. In 4 easy-to-read modules, Dr. Baucom shows the step by step way to save a marriage that is in danger of ending any day. These show the top 5 mistakes that most people make in marriage, the REAL secrets to a happy marriage, why marriage counseling can actually HURT your marriage more, and how to move beyond your emotions into action. This module can actually have you saving your marriage in less than an hour, sometimes even 10 minutes. This book also comes with 4 bonus gifts free: Coping With a Midlife Marriage Crisis, Recovering from an Affair, 5 Rules for Fighting Fair, and an eBook written by a couple who was on the edge of divorce and the methods they used to get a happy marriage back. Marriage can be hard, but divorce is harder, on you and your children. Why risk it? Continue reading...

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Shifting from Individual to Couple or Family Therapy

As noted throughout this chapter, interviewers should treat all couple and family members equally. We also have emphasized the tendency of relationship partners and family members to triangulate interviewers in an effort to have greater power or control in the therapy and family settings. For these reasons, we usually avoid the ubiquitous temptation to shift from individual to couple or family therapy with people from the same family system. We also advise against simultaneous individual and couple or family work by the same counselor. Our rules for handling this issue are Following completion of couple or family counseling, on rare occasions, we might consider working in individual therapy with one of the family members. However, when doing so, we always make it clear Once we start individual therapy, we will not return to couple or family therapy. An individual client says something to the therapist such as, Because we've already been working together, I trust you. I don't want to...

Family Therapy Outcome

Campbell (2002), in an extensive review of the family therapy outcomes literature on physical disorders concluded that there are no randomized control trials for marital or family therapy for adult illnesses. While this is strictly true, interest in research in this area has been on the rise, and there has been a significant increase in the number of studies assessing the outcome of family therapy. This healthy development can be found first in distinct research endeavors, namely, meta-analyses that use quantitative techniques to summarize the results of scientific studies on family therapy outcome (Shadish and Baldwin, 2003), and second, in evidence-based studies that determine primarily through a review of the research literature the efficacy of family therapy in treating a variety of disorders. Yet, as noted by Campbell, it can be said without any fear of contradiction that studies of family therapy outcome in relation to the medically ill population remain scarce. As was...

Family Therapy Journals

The American Journal of Family Therapy had more articles on heath-related issues and family than any other journal including the medical and pain journals. However, not one article was in the category of chronic pain and family. Two nonempirical articles with some relevance had to do with psychotherapy with physically ill patients and clinical issues in treating somatoform disorders respectively (Navon, 2005 Walsh and Denton, 2005). The Australian and New Zealand Journal of Family Therapy and the Journal of Family Therapy (U.K.) did not have any articles on chronic and family. Family Process similarly did not have a single paper on our topic, but had a number of family-related publications on chronic illness. The empirical reports included a study of family predictors of disease management with type 2 diabetes (Chesla et al., 2003 Fisher et al., 2000), coping with chronic illness using narrative analysis (Fiese and Wamboldt, 2003), an intervention with breast cancer survivors and...

Family Therapy

Family therapy can address complex family structures, such as that of the family discussed in this chapter the Laytons. Mrs. Layton, in her forties, suffered from chronic headaches. She was married to her second husband, Jim, and had two daughters, Jill and Jane, from her first marriage, both of whom were in college. Maureen, Jim's daughter from his first marriage, was a high school student when she joined this family. The structural changes were very apparent, and for that reason Minuchin's (1974) structural approach was used for the intervention. Mr. Layton, again on probing, stated that he did not think that the problems were that serious. He attributed some of the problems to their relatively new marriage and the fact that the children were growing up. This was a problem for him as well. However, he added that they had gone about bringing these two families together over quite some time. First, he and his daughter would just visit for a meal or just a social call and then they...

Contextual Influences On Temperament

Initial evidence showing how changes in individual temperament are associated with the nature of the child's environment typically involved assessment of negative emotionality during the first year of life. Specifically, Belsky, Fish, and Isabella (1991) have shown that infants who shifted from low to high negative emotionality during the first year of life had fathers who were both less involved with them early in infancy and who had greater feelings of marital dissatisfaction, as compared to infants whose level of negative emotionality remained low during this time period. In contrast, infants whose level of high negative emotionality declined over the first year of life had parents who had better marital relations and whose mothers displayed greater sensitivity, as compared to infants whose level of negative emotionality remained high during this time period. Similarly, Fish (1997) has reported that infants whose level of negative emotionality declined over the first year of life...

Health Risks Associated with Single Parent Families

While there appears to be a consensus that children of single parents, especially of single mothers, exhibit behaviors that range from antisocial to increased teenage pregnancy, there is contradictory evidence about increased health risks associated with single-parenthood. Harris and colleagues (1999) reported a very well designed study comparing adolescents from intact families, single-parent families, and blended families coping with type 1 diabetes mellitus (DM1). Data on wide-ranging medical, social, and psychological factors were collected on 119 adolescents and their primary caregivers. Of these, 65 resided in intact families, 38 in single-parent families, and 16 in blended families. Adolescent subjects had an average age of 14.3 years.

Therapeutic Approaches and Changing Family Patterns

When family therapy came of age in the late 1970s and early 1980s, while divorce was becoming increasingly commonplace, the nuclear family was most notably its focus. Almost all the major instruments to measure family function, such as the Family Environment Scale, the Family Assessment Device, and the Family Assessment Measure, were based on the functions of nuclear families. They continued to be used to determine the level of functioning of blended and single-parent families. In terms of family interventions, until recently, there was not much guidance to be had from the literature for treating a type of families that did not exist not so long ago. In this section we examine the kind of adaptation systems-based family therapy has made to deal with the very specific issues that these families encounter. There has been a veritable explosion of literature on therapy with single-parent families (Emery et al., 1999 Katz and Peres, 1995 Kissman, 1992 Korittko, 1991 Sargent, 2001 Westcot...

Case Illustration Mrs Gardner

It is equally important to recognize that Ann's behavior, while clearly antisocial, was not as a result of underlying psychopathology. She acted out to give vent to her anger and grief. Perhaps the fact that Ann returned to normal functioning so soon after Mrs. Gardner was able to resume her responsibilities confirms that much of Ann's behavior was a direct response to her mother's illness. It was a testimony to the central role Mrs. Gardner played in holding this family together. It is noteworthy that Mrs. Gardner was in psychotherapy during this entire period. Mr. and Mrs. Gardner also had an intensive period of couple therapy.

Suggested Readings And Resources

Feminism, community, and communication. Binghamton, NY Haworth Press. This edited volume contains nine essays and an interview with a family therapist trainer. It emphasizes the social construction of identity and examines the contribution of the dominant U.S. culture.

Pain as a Solution for Sexual Problems

Justification for his action without any guilt. Another woman used her backache to avoid sexual relations. She was very angry with her husband for her perceived neglect by him due to his studies. Whenever he sought sexual relations, she used her pain to opt out. There had been an imbalance in their sexual needs from the very onset of their marriage, and presumably pain provided her with an honorable way to terminate their sexual relationship.

Pain Behaviors and Marital Relations

In a couple with a history of satisfactory premorbid marital relations, the partner tends to be solicitous of the patient in the early stages of the illness, tends to adopt a very sympathetic and supportive attitude toward the patient, and actively engages in reinforcing pain behaviors. Yet, in the long run, in the absence of any discernible improvement in the patient's condition or, worse, further deterioration, the spouse may experience an increased sense of frustration and unexpressed grievance. A common problem encountered in family therapy in the area of communication is the feeling on the part of the well spouse that he or she has lost the right to give vent to negative feelings. From the patient's perspective, the problem is equally complex. Feelings of dependency combined with the loss of self-esteem lead to withdrawal and an unwillingness to communicate good as well as bad feelings. Patients and partners alike fall prey to poor communication, and under those circumstances...

We Want Whats Best for Each Other

Their marriage began to experience some difficulties. He became a semi-invalid, spending an inordinate amount of time in the supine position and giving every indication of being in great pain. From a strictly medical point of view, his level of disability was somewhat inexplicable. In the meantime, Mrs. Unrau and the children learned not to make any demands on him. His wife reported how on one occasion Mr. Unrau was about to carry some grocery bags from the car into the house, and she stopped him from doing it. She scolded him for not being careful. She was determined to protect him from anything that might aggravate his pain. Mr. Unrau was quite keen to undertake some chores around the house, but was actively discouraged. Nevertheless, Mrs. Unrau experienced considerable ambivalence about his level of disability. They were in a vicious cycle. The fact that they were caught in this cycle only became apparent in the course of psychotherapy.

Professional Background and Professional Affiliation

Finally, your professional background and professional affiliation can have a strong influence on what information is obtained in an intake interview. Before writing this book, we asked professionals from different backgrounds for their opinions about what was most needed in an interviewing textbook. The correlation between response content and respondents' areas of professional training was strikingly high. Psychiatrists emphasized the importance of mental status exam and diagnostic interviewing, based on the DSM-IV-TR. Clinical psychologists were interested in assessment and diagnosis as well, but they also emphasized problem assessment and behavioral and cognitive analysis. Counselors and counseling psychologists focused less on formal assessment and more on listening skills and helping strategies clinical social workers expressed interest in psychosocial history taking, treatment planning, and listening skills. Marriage and family therapists stressed the importance of...

Dont Think that Your Pain Is that

He was married and had a son, aged 9, and a daughter, aged 13. He was a highly trained craftsman, and was very committed to his work, which often required him to be on his feet for hours at a time. He never missed work. His wife, a healt-hcare professional, had serious doubts about the severity of Mr. Yost's pain complain and was vehemently opposed to the vast amount of prescription narcotic analgesic medication he was ingesting. This conflict was seriously affecting their marriage and his relationship with the children, especially with his daughter, who sided with the mother.

Evaluating Interpersonal Style

Interviewer It seems that in many of your relationships you tend to wait for others to meet your emotional and sometimes physical needs. Client Yeah, that's right . . . and I always end up waiting a long time too, don't I pull it off when the time is right. Interviewer Well, let's try something. Imagine your relationship with Sarah. What if, instead of waiting for her to call you, you took the initiative by calling her first and suggesting something you could do together Imagine doing that and then describe to me what thoughts, feelings, and images come to mind. Client Well . . . it's hard for me to even imagine doing that, but, well, she probably wouldn't want to do something I suggested. Or maybe she'd do it, but not enjoy it and then it would be my fault. I hate having all the responsibility for how things turn out. Interviewer It seems that in many of your relationships you tend to wait for others to meet your emotional and sometimes physical needs.

Mr Friesen A Case of Doing Ones Best

Friesen, a retired senior civil servant, presented with a multitude of pain complaints, the worst of them being his persistent pain from herpes zoster. He also had a long history of emphysema and periodic episodes of clinical depression. The marriage had a checkered history. The couple attributed their marital problems mainly to his long-standing health issues. Previously they had a daughter living with them who suffered from Down syndrome and was entirely dependent on them. The history revealed that the marriage ran into problems soon after their disabled daughter was born. Mrs. Friesen received very little practical or emotional support from her husband in raising the child, who subsequently died in her late teens.

Parenting Affection and Control

In most analyses based on children's reports of parental behavior and attitudes, two or three main factors emerge love or affection, punishment, and control. Correlations between children's personalities and parental behaviors and attitudes cannot establish any direction of causal effects, but they can show whether there are any such effects at all. We (Kraft & Zuckerman, 1999) correlated college students' scores on the Zuckerman-Kuhlman Personality Questionnaire (ZKPQ) with their reports of parental behavior and attitudes in intact families and broken families with a stepfather. The Impulsive Sensation Seeking (ImpSS) scores of males and females did not correlate with any of their perceptions of parental behavior and attitudes in intact families. In families with a stepfather, the daughters' ImpSS scores correlated positively with mother punishment and control scores and negatively with mother love scores, perhaps suggesting mothers' reactions to rebellious teenage daughters.

Physical Health Consequences

Reports on chronic pain and spousal abuse are few, and most of them acknowledge that chronic pain is commonly observed in abused spouses and partners (Dienemann et al., 2000 Haber and Roos, 1985 Kendell-Tackett et al., 2003 Plichta, 2004 Rapkin et al., 1990 Woods, 2004). A few of these studies were designed specifically to determine if there is a direct relationship between abuse and pain. One of the early studies, Haber and Roos (1985), investigated 153 women attending a pain clinic 53 of these women reported abuse. Of these women, 78 were abused for the first time in their marriage. The mean duration of abuse was 12 years. In all cases pain problems followed incidents of abuse. This study was entirely based on patient interviews, and no standardized questionnaires were used. Yet the findings of this study cannot be dismissed, given the magnitude of the abuse uncovered.

Schedule Performance in Transition

Transitions in the schedules of reinforcement also occur with major life events. Significant life events that produce shifts in schedules of reinforcement include going to school, making a living, getting married, having children, divorcing, and experiencing the death of a loved one. The authors are familiar with the shift in contingencies of reinforcement that happens following a divorce. A person's sexual behavior may have to adjust to new requirements. This adjustment involves finding new partners and meeting the contingencies set by these individuals. Some people who go through a divorce may not be able to meet the new contingencies of reinforcement. Feelings of loneliness and depression often accompany marital breakdown. These feelings may be generated by ratio strain and extinction that result from a change in the contingencies of reinforcement. In contrast, there are people who readily adapt to this life crisis. Presumably, behavioral variability and an initial flurry of...

Discussing Confidentiality and Informed Consent

Teenagers need to hear how privacy is maintained and protected. Further, most parents appreciate their children's need to talk privately with someone outside the home and family. In the case of a diagnostic interview where results are shared with a referral source or a child study team, the child should be made aware of this. In rare cases where parents insist on being in the room continuously or constantly apprised of therapeutic details, a family therapy or family systems interview and intervention is probably most appropriate.

Children and the Culture of Divorce

I have the right to be free from your conflicts and hostilities. When you badmouth each other in front of me, it tears me apart inside. Don't put me in the middle or try to play me against my other parent. And don't burden me with your relationship problems, they're yours, not mine.

Some Day I Am Going to Leave This

The chronicity of her stressful family life may also have contributed to the psychophysiological nature of the headache. She remained in psychotherapy for about 18 months. Psychotherapy did not altogether alleviate her headaches, although they were substantially modified. Her self-esteem was vastly improved, and eventually Rose did leave her husband. Following the separation, her husband contacted her therapist seeking counseling. Rose was unwilling to take part in joint therapy. This man was referred to another psychotherapist. It is noteworthy that soon after Rose appeared at the pain clinic, the therapist made many overtures to the husband to engage in marital therapy. He firmly declined.

Some Ironies Of Interviewing Couples And Families

Couples and families usually come to counseling with different motivation levels, expectations, and agendas among the members. Some of the family or one of the couple may be openly reluctant to even try counseling. This imbalance may lead to premature termination. Additionally, most insurance companies and many managed care organizations do not provide insurance reimbursement for couple or family therapy. This reduces the length of time the family or couple can afford therapy, thus further increasing the pressure to provide efficient interviewing and counseling services. Finally, logistically, it is hard for busy couples or families to find a time when everyone can consistently attend therapy sessions. Difficulty scheduling may reduce the time couples and families spend in counseling.

An Older Retired Couple

This case is instructive for a number of reasons. First, Mr. and Mrs. Friesen surprised themselves and the therapist by the rapid increase in Mr. Friesen's level of activities and Mrs. Friesen's ability to experience the emerging partnership that truly had not existed in this marriage for a very long time. Second, couple therapy for the elderly is not common, which could be explained, in part, as a function of agism in our society. Yet, at least on the basis of this case, there is clear evidence that, with minimum intervention, an elderly couple can achieve a level of improvement that surpasses everyone's expectations.

Psychosocial Aspects and Quality of Life

The importance of involving, educating, and equipping partners with the relevant information and skills so that they can empower and support the patient to reach informed decisions should not be underestimated. In the absence of such interventions, the potential for misconceptions, misguided beliefs, and marital conflicts can increase, perpetuating further uncertainty, fear, and loss of control as well as precipitating physical symptoms.17

To Keep Secrets or to Not Keep Secrets

When she calls for the appointment, Sandy tells you that she had been having an affair for the past year, but that she has stopped seeing the other man. She also tells you that she hasn't informed Rick about the affair and that she's not sure she needs to. What do you tell her about your policy on secret-keeping in couple therapy Before you begin taking couple therapy referral calls, get clear on your policy. We know some therapists in our community who not only refuse to keep secrets, but who also directly ask possible couples therapy clients if there is an affair happening. If the caller indicates there is an affair (or a suspected one), these therapists refuse to initiate therapy until the love triangle has been discussed and terminated by the couple. important that I get an idea of what's been going on and what brought you here. I hope we can also talk about how family therapy might help. Family therapy openings are wide-ranging, depending on the interviewer's theoretical...

HOME and Socio Emotional Development

Findings by Bakeman and Brown (1980) Lamb et al. (1988) Erickson, Stroufe, and Egeland (1985) Mink and Nihira (1987) Bradley, Caldwell, Rock, Barnard, Gray, et al. (1989), Caughy, DiPietro & Strobino, 1994, and Bradley and Corwyn (2000, 2001) suggested that particular parenting practices may interact with both particular child characteristics (e.g., quality of attachment, difficult temperament, self-efficacy beliefs, level of disability) and broader ecological factors (e.g., marital quality, support from extended family, participation in day care, family conflict, overall family style) to affect the course of social development. Moreover, the study by Plomin, Loehlin, and DeFries (1985) showing little relation between HOME and behavior problems in adopted children but a significant, yet small (.23), relation for nonadopted children suggests that genetic factors may play a role. A child's reaction to a particular parent action also is a function of the overall ambiance or style (e.g.,...

Behavioral Approach

Despite very convincing evidence about the spousal role in pain-reinforcing behavior, reports of therapeutic intervention with this problem are sparse. Cognitive-behavioral therapy, which has proven to be one of most effective tools in the armamentarium of psychotherapists in treating chronic pain, has not made its way into couple intervention with pain problems. However, one report on cognitive behavioral group treatment for pain patients and their spouses found an improvement in many parameters of marital satisfaction, in coping with pain, and in psychological distress in participants and their spouses (Langelier and Gallagher, 1989). The studies are focused on the family and on a broader scope than just spousal behavior. Even with systemic couple therapy with chronic pain, there are only three reports, from the same authors, that demonstrated its efficacy in treating subjects with chronic low back pain and their partners (Saarijaarvi, 1991 Saarijarvi et al., 1991, 1992). It is...

Formal Couple And Family Assessment Procedures

Marital Satisfaction Inventory (MSI), D. Snyder, 1981 The assumption underlying this measure is that environments, such as families, have unique personalities that can be measured in much the same way as individual personality. Thus, the 90-item family environment scale seeks to measure the unique social climate within the family. The family genogram is a procedure that enables therapists to graphically represent family structure. It is very popular among family therapists. The genogram is essentially a visual map of family relationships. It contains factual information such as names, ages, deaths, divorces, etc., as well as relationships. This instrument is a self-report designed to assess marital interaction and marital distress. It includes 11 subscales (e.g., problem-solving communication, disagreement about finances, sexual dissatisfaction). The inventory should be completed by both partners and results are graphed on a single profile so that partner differences can be...

Limit Setting with Couples and Families

Scenario 2 The Johnsons have been referred by youth court for family therapy. The family includes Margie Johnson, mother of twins Rick and Roy Johnson, and Calvin, Margie's live-in boyfriend. Margie is 37 and the twins are 15. Calvin has lived with Margie and the twins for the past three years. His daughter, Mollie, visits on weekends. The boys' father is currently in prison for forgery and has not seen the boys since they were infants. During the initial visit, Margie, Roy, Rick, and Calvin are all present. The twins begin having a burping contest and Margie gets the giggles. Calvin does nothing. The counselor waits until things settle down and then asks another question. Roy and Rick both burp in response. Margie begins laughing again. No one responds to the question. Discuss the following questions.

The Multidimensional Assessment Of Exposure To Community Violence

Ritchie, 1991 Osofsky et al., 1993 Jaffe, Wolfe, Wilson, & Zak, 1986 McCloskey, Figueredo, & Koss, 1995 Jouriles, Murphy, & O'Leary, 1989 Crockenberg & Covey, 1991). For example, in nonclinical samples, preschool children exposed to marital discord showed more externalizing behavior problems, including aggression and noncompliance (Crockenberg & Covey, 1991). A recent meta analysis examining 118 studies of children exposed to interparental violence indicate a low-to-moderate effect size (d -.29) on child problems (Kitzmann, Gaylord, Holt, & Kenny, 2003), with greater exposure risk shown among preschoolers.

You Are Almost Always Not the Only Competent Therapist in Town

An excuse often offered for doing individual, couples, and family work interchangeably with the same people is that the people involved insist on it. Underlying their preference is their belief that you have done excellent work. This is flattering, but not a convincing argument. Choosing to cross the boundaries and do the additional work can, in fact, undo some of the good work you did in the first place. Avoiding dual roles, an ethical guideline present in all mental health professional ethics codes, includes avoiding being someone's family therapist and individual therapist if being in both roles may cause you to lose objectivity (ACA, 1995 American Psychological Association, 1992).

Evidence Based Therapy

The evidence-based approach to family therapy has its critics (A. Campbell, 2002). Nevertheless, the momentum for empirically validated treatment or evidence-based treatment is increasing, and despite its political and other ramifications, evidence-based therapy minimally forces the therapist to rely on the conclusions of a review of outcome studies rather than solely on personal preference. We review three reports on the efficacy of family therapy with marital relations. On the broad question of the effectiveness of family therapy, a body of opinion now exists that suggests that family therapy is indeed an effective therapy to deal with a multitude of problems that range from psychiatric disorders to marital and family conflicts (Carr, 2000a,b Rivett and Street, 2003). A minority view is that such optimism is a little premature (Roy and Frankel, 1995). In a very thoughtful analysis of the literature on the effectiveness of family therapy, Rivett and Street (2003) raised this critical...

Family Reinforcement of Sick Behavior

No specific differences have been found between families of well children and those of children with chronic pain on family measures like marital satisfaction and cohesion (4). However, some clinical evidence suggests that these families may differ in areas not gaged by standardized instruments. Overprotectiveness and enmeshment are two of these areas. Walker suggested that social modeling of pain may contribute to recurrent pain episodes among children, particularly if the child vicariously observes a parent receiving attention from other family members if there are complaints of pain. Levy and coworkers noted that a child may learn pain behavior when caregivers seek extensive medical consultation for pain (16). Walker noted that caregivers of children with abdominal pain may view their children as vulnerable, and these caregivers may attempt to protect their children from potential health-related threats (4). This pattern may result in caregivers letting a child stay home from...

Behavior Is the Primary Focus

Applied behavior analysts focus on the behavior of people. Behavior is not considered to be an expression of inner causes like personality, cognition, and attitude. Marital difficulties, children who are out of control, littering, phobic reactions, poor performance on exams, excessive energy use, and negative self-descriptions are analyzed as problems of behavior. Interventions for these and other problems are directed at changing environmental events to improve behavior.

Diabetes and Sexual Dysfunction

Another study found confirmation for the physical causes for sexual problems in diabetic men (Schiavi et al., 1995). Compared to healthy controls, diabetic patients had significantly lower levels of erotic drive, sexual arousal, enjoyment, and satisfaction. Problems in these areas coexisted with alterations in sexual attitudes and body image, but were not related to group differences in marital adjustment as reported separately by the patients and their partners. Most critically, there was no evidence that psychological distress and psychiatric problems were associated with diabetes or with its effects on sexual function. The authors cautioned that measures of marital adjustment may not be sufficiently sensitive to reflect the sexual impact of diabetes on marital relationship. They suggested that it was possible for the couple to develop compensatory applications to the limitations posed by the disease, and ultimately the value attributed to nonsexual aspects of the relationship may...

Blood Circulation And Transfusion

Of a Quaker to be let into an Archbishop and such like' (Nicolson, 1965). It was also proposed that the phlegmatic personality could be corrected by transfusion with blood from a choleric, and even that marital discord could be settled by reciprocal transfusion of husband and wife.

Premorbid Sexual Problems

Another headache sufferer had felt mentally abused by her husband throughout their marriage, had no sense of intimacy with him, had serious doubts about whether or not she loved him, and actively avoided any sexual relationship with him. Their sexual relationship was intermittent, and over the years the husband had become less and less interested in sex to the point that all sexual relations had ceased. The reasons for the decline in sexual activities in these cases are self-explanatory. Pain did not create the sexual difficulties, and perhaps only nominally aggravated the problem. In some instances, the emergence of the pain problem legitimized the lack of sexual relations. To reiterate, a limited or nonexistent sexual relationships between these couples was a true manifestation of underlying or deep-seated marital difficulties, the central feature of which was the absence of an affectional bond between the couples.

Is This Paternalism or Abuse

Jacky was in a classic emotionally abusive situation. To have to account for all her activities and every penny spent was more than just controlling behavior. Yet, from her husband's perspective, she was a defiant and, even worse, an irreligious person. In his culture and religion, the woman's place was well defined. The man was in charge. More seriously, however, the marital conflict produced a host of medical and psychological problems. Whether her anorexia, which persisted throughout her marriage, was a product of abuse is unclear, but her anxiety and depression were. For the most part, Jacky felt abandoned. Did her husband's behavior border on sexual abuse A case can be made in the affirmative. To force sex on a physically compromised person, on the ground that it was his right, is tantamount to abuse. The emotional cost of this marriage for Jacky was enormous. Jacky remained in therapy, on and off, for 5 years. Her situation demanded ongoing psychological therapy and support.

Newly Married Couple

The presenting problem is a difficult area in relation to couple or family therapy with chronic pain sufferers. At the center of this issue is the presence of an unresolved medical problem and the patient's and indeed family member's capacity Problem solving looks at a couple's or a family's ability to resolve its difficulties and how harmoniously problems are resolved. In the context of this couple, it is imperative that the family life-stage issues be considered. They had been married for only 7 months their marriage was already complicated by a pain problem in one partner. The ability of a newly married couple to solve problems in a mutually satisfactory way is one long process of trial and error accompanied by a desire to acquiesce. Newly married couples also have an enormous propensity for denying problems. This couple had an unfortunate start to their married life. Their expectations from this alliance were at variance. They were confronted with all the difficulties of building...

The Health of the Partners Spouses and the Children

Even a passing review of the literature on the health of caregivers of chronically ill patients provides, ample evidence of the vulnerability of the caregivers on many fronts. One study, for example, found that depression was a major predictor of caregiver well-being in a sample of 142 caregivers of chronically ill family members (Berg-Weger et al., 2000). Depression explained 56 of the variance in activities of daily living, and 64 of the variance in basic needs. Depression also emerged as a mediator between stress and well-being. Another study investigated spouse-caregiver attachment style and the couple's communication style on spouse-caregiver depression and marital satisfaction in a group of 52 couples where one spouse had cancer, Alzheimer's disease, or stroke (Harkness, 1997). The conclusion was that depressive symptoms were common among the caregivers. Women who were anxiously attached, who encountered disagreement from their ill partners after trying to engage them in...

Further Thoughts on Mrs Christy and Her Family

We adopt an eclectic, albeit systemic, family therapy approach in discussing Mrs. Christy's case. First and foremost, family is an organization with hierarchy, roles, rules, styles of communication, affectional bonds, and mutual obligations. The executive function of the Christy family, the domain of the two parents, was seriously challenged with the onset of Mrs. Christy's chronic pain problems. Normally, with Mr. Christy's regular absence from home, a good deal of the executive functions were carried out by Mrs. Christy. Her inability to satisfactorily attend to the multifarious needs of this family, from decision making on a whole host of matters ranging from preparation of food, to paying bills, to attending to her children's needs, came under strain. From a structural point of view, every subsystem of the Christy family changed for the worse. The relationship between the parents, between the parents and the children, and between the children had to undergo some major changes in...

Who Does What An Exploration of Family Roles

A great body of research findings now exist on the impact of women in the work force and a variety of family roles. Any broad conclusion is complicated by class, culture, and demographic factors. Nevertheless, in a major review on this topic, Coltrane (2000) was able to draw a few conclusions. One conclusion is that women have reduced and men have increased slightly their hourly contributions to housework, although women still do twice as much housework as men. When men perform more of the routine housework, employed women feel that the division of labor is fairer, they are less depressed, and they enjoy higher levels of marital satisfaction. These observations have serious consequences when a partner develops chronic illness, and the impact is experienced differently depending on whether it is the male or the female partner who is affected. Furthermore, the presence of young children is an added consideration. In general, confronted with job loss it is harder for a wife and mother to...

Evidence That Psychosocial Factors Predict CHD Events

In addition to perceived stress at work, stressful conditions in family life have been shown to increase CHD risk. In Stockholm, marital discord was found to worsen prognosis in women with an acute coronary syndrome and to reduce event-free survival over and above the effects of standard clinical prognostic factors.7 Although a majority of the women were employed outside the home, the hazards of marital stress were stronger than those of stress at work in these women. Among working women (n 200), work stress did not

Program Structure Staffing and Content

Few programs in China use cardiovascular risk stratification or treatment goals determined by national guidelines. However, with the difference in epidemiology of risk factors between Chinese and Caucasian patients with coronary heart disease4 and the limited applicability of some risk score scales in clinical practice (such as the Framing-ham score),5 it is necessary to re-evaluate the impact of risk factor modification on the progression of the disease.

Case of Chronic Headache

The Christy family members were seen together for an assessment. Mr. Christy was devastated by his wife's accident. Yet, at the same time, he was somewhat mystified by her degree of disability in view of all the negative medical findings. Mr. Christy had become short-tempered, withdrawn, sad, and angry, and he made very little effort to conceal his thoughts and feelings. Throughout their marriage he had depended on his wife to manage the household, the finances, and the day-to-day needs, of the children, a duty she had fulfilled admirably with joy and pride. Now he could no longer depend on her. The problems were complicated by his periodic need to go on business trips. Mr. Christy's anxiety centered on the

Exploring Societys Contributions to Client Problems

That client problems must be viewed in their social and cultural context is an unarguable fact. Articulating this point for families in particular, Goldenberg and Goldenberg (2000) describe the discoveries made by renowned family therapist Salvador Minuchin (Minuchin, Rossman, & Baker, 1978).

He Is Not Well Enough to Do Much

From a clinical point of view, when illness or even persistent symptoms, unbeknown to the affected parties, begin to resolve long-standing marital conflicts, it presents a challenge of insurmountable proportions. This case illustrates the point. Mr. Vince was involved in a minor car accident in which he sustained a whiplash injury. Following the accident, he decompensated rather rapidly and his functional capacity decreased dramatically. He was married for 7 years, and the marriage was characterized as argumentative. The central source of this conflict was Mrs. Vince's conviction that her husband was destined for a better life. She was clearly ambitious for him. On his part, he was easygoing and quite content with his way of life. Nevertheless, he felt unfairly criticized by his wife for his seeming lack of drive. Mr. Vince had no problem in slipping into the role of a chronically sick individual, and Mrs. Vince provided much reinforcement for him to maintain that role. The accident,...


Who could have predicted that in a short period of 25 or 30 years the nuclear family would have fallen from its pivotal position, that nearly 30 of the adult population would live in one-person households, that the stigma associated with children born out of wedlock would disappear, that divorce and remarriage would become commonplace, that single-parent families would become dominant, that living in common-law marriages would have legal sanction, that same-sex couples would gain some recognition and acceptance, and that dazzling technological advances would begin to reverse infertility and give rise to new types of families These and other less prominent phenomena, such as single women choosing to have babies in their late thirties or even early forties, are current realities. A case can be made that the family therapy literature, at least in part, has not entirely kept pace with the rapid and dramatic changes in family structure in recent times. This chapter has identified this...


Now I want to summarize the four main issues you've discussed today. First, you said your childhood was hard because of your father's authoritarian style. Second, in your current marriage, you find yourself overly critical of your wife's parenting. Third, you described yourself as controlling and perfectionistic, which you think contributes to the ongoing conflict in your marriage. And fourth, uh, fourth long pause , uh, I forgot what was fourth but I'm sure it will come to me.

Does He Really Care

Falconer who suffered from serious back pain complained that her husband was profoundly indifferent to her suffering. The marriage had a troubled history. Mr. falconer seemed to lack any understanding of the severity of her pain problem except in one remarkable respect he took over, without complaint, all the household chores, including cooking, and was supportive of her at a very practical level, like driving her to medical appointments and on other errands. Perhaps, by taking over her responsibilities, he continued to reinforce her sick role and extricated himself from marital conflicts. The added responsibilities and the loss of hope of a recovery in this case did not seem to have any adverse consequences on Mr. Falconer.

Discussion of Cases

The first two cases were selected because they represented the most common kind of health problems encountered by the spouses of chronic pain patients. The question of burden in the chronic pain population is generally associated with more responsibilities for the well partner, accentuated by financial problems. Anxiety and depression are the most common reactions noted in the partners of chronic pain patients. The case of Mrs. Falconer is complex, as it seems to suggest that her illness resolved a long-standing marital conflict, although there was a major shift of responsibilities from the patient to the well spouse without any ill effect. Whatever additional burden Mr. Falconer had to assume due to his wife's chronic condition, her illness apparently removed their differences, and that was enough compensation for Mr. Falconer.

Mrs Christy

This was resolved in therapy. Mrs. Christy, to her credit, even on bad days tried to manage the family affairs from her bed. Over time, and with limited family therapy, this family adjusted well to Mrs. Christy's affliction, and the children's health was not adversely affected.

Case Illustrations

Yost and the rest of the family virtually ceased. This absence of communication is another point not readily recognized by the various models of family therapy. It is not just the quality of communication but also the quantity that was affected in the Yost family.


For example, if resistance is manifest through discussion of irrelevant or inane topics, you may say, I notice when we begin talking about how your relationship to your spouse might be making you more depressed, you usually begin talking about television shows, how this office is decorated, international issues, and anything but your relationship with your spouse. Sometimes, simply noticing resistance patterns, similar to a confrontation, encourages clients to examine their behavior and begin making constructive changes.

The Christy Family

Emily, 10 years old, spent all her waking hours by her mother. She went to school rather reluctantly and gradually cut herself off from her large circle of friends. It is important to emphasize that while both children were distressed, their behaviors were worrying without being alarming. Mrs. Christy decided to seek family therapy. The outcome was very positive. The children's response to their mother's illness and their father's anger toward George was not extraordinary. Emily was frightened and sad, as was George, but George was also perplexed by his father's change of attitude. Potentially these children were at considerable risk, but early intervention and the capacity of the parents to recognize the children's distress and take remedial measures proved to be effective.


The fourth family, the Christy family, was different from the first three in several respects. First, the parents were highly educated and were high earners. Mother, while periodically disabled by her pain, was still functioning, albeit somewhat erratically and unpredictably. Above all, the parents demonstrated very good judgment by seeking family therapy and making the necessary changes to normalize family life. Both parents were totally committed to ensuring their children's well-being.

The Yost Family

Yost (see Chapter 5), despite his long history of pain and disability, persisted in a rather demanding job. There was great deal of marital conflict, which centered on his intake of narcotic analgesics. His wife, a health-care professional, was not convinced of the gravity of her husband's pain problems and could find no justification for his dependency on narcotic drugs. They had a daughter Heather, age 13, and a son Jo, age 9. Mr. Yost's relationship with his son was excellent, but that could not be said about his relationship with his daughter.

Emotion Research

Older adults and younger adults show similar skin conductance responses to emotional pictures (Denberg, Buchanan, Tranel, & Adolphs, 2003). Older adults, however, demonstrate smaller changes in cardiovascular responses during such emotional events as recalling relived emotions, discussions about marital conflict, and viewing film clips (Levenson, Carstensen, & Gottman, 1994 Levenson, Friesen, Ekman, & Carstensen, 1991 Tsai, Levenson, & Carstensen, 2001). Across the various studies, this dampening of cardiovascular responses among older adults is not associated with any decrease in the degree of subjective emotion or behavioral responses to emotional events, compared with those of younger adults. Older adults report as much intensity in their everyday emotions as younger adults do (Carstensen et al., 2000). Apparently, changes in cardiovascular responsiveness to emotional events do not cause older adults to experience emotional events differently. Thus, on the whole, there seem to be...

Course of Illness

Baseline hyperthymic personality is another important course feature to assess (Cassano et al. 1992 Perugi et al. 2001). Obviously, when one is evaluating mood episodes, it is important to compare them to patients' baseline mood states, which, in effect, represent the usual personality of the patient. Hyperthymic personality is a state in which one is chronically hypomanic, with a personality that is bubbly, outgoing, and very extroverted. Typically, such persons need less sleep than most individuals (6 hours or less), and have a great deal of energy that they spend in work (workaholism) and social activities. They often also have a good deal of libido, and can have more interpersonal marital conflicts due to sexual indiscretions than the general population. Hyperthymic personality has been reported to be more frequent in families of persons with bipo


The central statements regarding confidentiality from the American Psychological Association's (APA 1992) Ethical Principles are included in Table 2.1. For a contrasting perspective, key statements from the Codes of Ethics for the American Counseling Association (ACA 1995) are provided in Table 2.2. We should note that the National Association of Social Workers (NASW 1996) and the American Association for Marriage and Family Therapy (AAMFT 1991) also have ethical guidelines pertaining to confidentiality. Welfel (2002) summarizes the concept of confidentiality by stating a. Psychologists discuss with persons and organizations with whom they establish a scientific or professional relationship (including, to the extent feasible, minors and their legal representatives) (1) the relevant limitations on confidentiality, including limitations where applicable in group, marital, and family therapy or in organizational consulting, and (2) the foreseeable uses of the information generated...

The Systems Approach

This section discusses couple therapy with chronic pain sufferers and their partners. As a rule, couple therapy is initiated by the therapist, which usually takes a good deal of the time, because such a suggestion often meets with varying levels of resistance from the patient. Nevertheless, couple therapy can yield benefits. There is little debate in the psychotherapy literature that the success of therapy largely depends on the couple's being motivated. This is an important point, as some of our patients or their partners engage in therapy with some reservation. They do not come to a pain clinic for psychological or marital help. We will explore the application and process of couple therapy with two couples at different family stages (1) a newly married couple without children, where one partner has serious problems with headaches and (2) an older retired couple (the Friesens see Chapter 7), where one partner has multiple health problems. Problem-centered systems family therapy...

Defining Couple

There is disagreement and discomfort in the professional and general population regarding how to define a couple (e.g., Hawkins, 1992 B. Murphy, 1992). Some professionals advertise marriage or marital therapy others use the term couples counseling or couples therapy. Our position on the couple versus marital therapy issues is based on inclusion. Throughout this chapter, we refer to interviewing and counseling techniques that include two people who are pursuing a romantic relationship together primarily as couple work. Couple counseling may involve therapy with unmarried gay and lesbian couples, unmarried heterosexual couples (who never plan to marry), unmarried couples (who are pursuing premarital counseling), couples who have made a life commitment they regard as marriage, even though not legally recognized, and traditional, legally married couples. It also includes couples who are divorced and reconciling. In contrast, marital therapy refers specifically to therapeutic efforts...

Defining Families

Like the definition of a couple, the definition of a family has, unfortunately, become a politically loaded topic. It is difficult to make statements about families without encountering opposition. We believe families come in all shapes and sizes. Family theorists and therapists differ with regard to whether they will treat subsets of family members when conducting family therapy (Goldenberg & Goldenberg, 2000). However, in our transient, mobile society, at any given time, the family may be defined and configured differently than it was a week ago or than it will be next week. Children in coparenting situations often see themselves as actually having two or more families. Children raised in extended kinship systems, as reflected in many American Indian and other cultures, may live for periods with grandparents, aunts, uncles, or older siblings. Families may contain foster children, elderly relatives, and part-time members. They may be headed by one parent, two parents, a grandparent...

The Introduction

Much of the previous advice can be applied to initial family therapy telephone contacts. The primary difference is that it is unusual for a family member to call with a clear request for family counseling. The request for help usually centers on a description of certain troubling patterns of behavior in the family, or (more commonly) in one or more members of the family. Both theoretical orientation and clinical judgment must be involved in determining whether family therapy or individual therapy with or without family member consultation is the treatment of choice. When someone calls to request help with a situation that might best be handled by family therapy, it is advisable to arrange a time when all family members can be present for an initial interview. You may not continue to have all members attend, but meeting everyone who lives in the family home is standard when initiating family therapy. Many family therapists or clinicians with a family systems orientation are insistent...

Conflicts of Loyalty

Perhaps the greatest reason to avoid shifting from individual to couple or family therapy is that conflicts of loyalty inevitably ensue. Specifically, unless the therapist makes great efforts to build trust and rapport with the original client's romantic partner or family, the new parties are likely to believe the therapist holds a deeper loyalty to his or her original client. Additionally, if the therapist, for whatever reason, sides with the new therapy client against the original client, the original client may feel betrayed and abandoned. Consequently, the therapist can become stuck in a no-win therapy bind both or all clients may quickly suspect the therapist has already sided with the original client, or has switched allegiances. Such dynamics can add unnecessarily to an already difficult therapy task.


Life-stage issues combined with a blended family situation had a negative effect on Mrs. Layton's headaches. Strengthening of the couple's bonding was the single most important factor in bringing about a positive outcome. Unfortunately, many patients seen at a pain clinic are far more disabled than Mrs. Layton, and as was evident throughout this volume, are confronted with serious upheaval in their families. Because of the obvious structural issues the Laytons were facing, a modified version of Minuchin's structural approach was adopted with some modicum of success. The efficacy of family therapy with this population and the medically ill population remains a question. We explore these issues in the following section.

Telephone Contact

Interviewers vary greatly in how they inform clients of financial arrangements, session lengths, and intake procedures. Some leave these duties to trained office personnel. Some provide the information in written form. Others go over it verbally with the client before the first session. Still others give this information during the interview. The important point is that first contact, whether via mail, phone, questionnaire, or in person, directly affects your relationship with clients.

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