An Unhappily Married Patient
Am Fam Physician. 2019 Jun 1;99(11):708-710.
A 45-year-old woman presented to my office with initial symptoms of headaches and insomnia. My initial screening showed mild depression; her physical examination was normal. I asked her how things were at home, and she told me that she and her husband fight all the time. She added that her husband complains that they never have sex and that she is afraid he may be interested in a coworker. She stated that her attempts to talk with her husband about their situation have been met with anger and defensiveness. She is beginning to shut down her feelings in the relationship.
During my training, I was encouraged to explore relationship issues between committed partners; however, doing this in a busy office setting is challenging. What practical recommendations can be offered? What indicators should prompt a more thorough evaluation and/or referral for additional care?
Overall, marriage enhances health.1 Men gain greater health benefits from marriage than their wives. Conversely, wives are more negatively affected by a bad marriage than their husbands.2,3 In general, the health benefit of marriage is maximized in a good marriage but negated in a bad marriage.4,5
Physicians receive little training in couple dynamics, however. Only a few articles in the medical literature address the treatment of interpersonal stress in committed couples. This is particularly alarming because family physicians have traditionally been trusted to address family issues, and patients want family physicians to be knowledgeable about and helpful with these issues.6
Women are more likely to share concerns in the physician's office7; however, men may be willing to share if properly encouraged with open-ended questions. Relationship issues present in same-sex marriages are similar to those in heterosexual marriages. The goal is to address the patient's concerns with appropriate sensitivity while remaining on schedule during a busy clinical day.
First, gather information about the marital situation in a timely manner. Be aware of the risk of triangulation; physicians should remember that they are hearing only one side of the story and should be careful before recommending specific actions without obtaining a complete picture. Physicians should also make every effort to be sensitive to cultural differences about marriage and to be self-aware of unconscious bias.
Physicians can achieve a relatively complete picture in a short amount of time by asking these questions:
How did you and your spouse meet?
How long have you been in your partnership?
Is this your first marriage?
Do you have any children or grandchildren?
What types of external stressors (e.g., money, career, in-laws, medical issues) currently affect your relationship?
Have you tried anything to fix this problem?
What would your spouse say about this situation if your spouse were in the office now?
What bothers you the most about this situation?
What are you willing to do to help this situation?
Would it be okay if I offer some suggestions?
Would you be willing to attend couple therapy with your spouse? (It is helpful if you ask patients whether they have past experience seeing therapists or whether any barriers to seeing a therapist [e.g.,
Referencesshow all references
1. Robles TF, Slatcher RB, Trombello JM, McGinn MM. Marital quality and health: a meta-analytic review. Psychol Bull. 2014;140(1):140–187....
2. Kiecolt-Glaser JK, Glaser R, Cacioppo JT, et al. Marital conflict in older adults: endocrinological and immunological correlates. Psychosom Med. 1997;59(4):339–349.
3. Kiecolt-Glaser JK, Newton TL. Marriage and health: his and hers. Psychol Bull. 2001;127(4):472–503.
4. Ross CE, Mirowsky J, Goldsteen K. The impact of the family on health: the decade in review. J Marriage Fam. 1990;52(4):1059–1078.
5. Holt-Lunstad J, Birminghan W, Jones BQ. Is there something unique about marriage? The relative impact of marital status, relationship quality, and network social support on ambulatory blood pressure and mental health. Ann Behav Med. 2008;35(2):239–244.
6. Hansen JP, Bobula J, Meyer D, Kushner K, Pridham K. Treat or refer: patients' interest in family physician involvement in their psychosocial problems. J Fam Pract. 1987;24(5):499–503.
7. Mental Health Foundation. Survey of people with lived experience of mental health probems reveals men less likely to seek medical support; November 6, 2016. https://www.mentalhealth.org.uk/news/survey-people-lived-experience-mental-health-problems-reveals-men-less-likely-seek-medical. Accessed April 1, 2019.
8. Nelson T. Date nights: they make your marriage work. Huffington Post. Updated April 9, 2012. https://www.huffpost.com/entry/date-nights-they-make-you_n_1264207. Accessed March 1, 2019.
9. Gottman J, Silver N. The Seven Principles for Making Marriage Work. London, United Kingdom: Cassell Illustrated; 2018.
10. Carson JW, Carson KM, Gil KM, Baucom DH. Self-expansion as a mediator of relationship improvements in a mindfulness intervention. J Marital Fam Ther. 2007;33(4):517–528.
11. Kimmes JG, May RW, Siebert GS, Jaurequi ME, Fincham FD. The association between trait mindfulness and cardiovascular reactivity during marital conflict. Mindfulness. 2018;9(4):1160–1169.
12. Rogge RD, Cobb RJ, Lawrence E, Johnson MD, Bradbury TN. Is skills training necessary for the primary prevention of marital distress and dissolution? A 3-year experimental study of three interventions. J Consult Clin Psychol. 2013;81(6):949–961.
13. Aron A, Norman CC, Aron EN, McKenna C, Heyman RE. Couples' shared participation in novel and arousing activities and experienced relationship quality. J Pers Soc Psychol. 2000;78(2):273–284.
14. Wilson DM, Cash TF. Who reads self-help books? Development and validation of the self-help reading attitudes survey. Personality and Individual Differences. 2000;29(1):119–129.
15. Cuijpers P. Bibliotherapy in unipolar depression: a meta-analysis. J Behav Ther Exp Psychiatry. 1997;28(2):139–147.
16. Johnson SM, Hunsley J, Greenberg L, Schindler D. Emotionally focused couples therapy: status and challenges. J Clinical Psychology: Science and Practice. 1999;6(1):67–79.
17. Makinen JA, Johnson SM. Resolving attachment injuries in couples using emotionally focused therapy: steps toward forgiveness and reconciliation. J Consult Clin Psychol. 2006;74(6):1055–1064.
Case scenarios are written to express typical situations that family physicians may encounter; authors remain anonymous. Send scenarios to email@example.com. Materials are edited to retain confidentiality.
This series is coordinated by Caroline Wellbery, MD, Associate Deputy Editor.
A collection of Curbside Consultation published in AFP is available at https://www.aafp.org/afp/curbside.
Please send scenarios to Caroline Wellbery, MD, at firstname.lastname@example.org. Materials are edited to retain confidentiality.
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