Case Scenario

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?

Commentary

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

Management

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.

INTERVIEWING

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., cost, pride, fear] would keep them from following through.)

RECOMMENDATIONS FOR SOLUTIONS

Several real-world recommendations are effective for unhappily married patients when addressing typical problems, including fighting, sexual libido incongruities, and trust and communication issues. Table 1 lists examples of simple suggestions to help spouses connect.⁸

Constant Fighting

• Take a 10-minute break if fighting gets intense; discuss again only after both parties have calmed down.

• Express more appreciation to your spouse; a five-to-one ratio of positive to negative interactions is associated with marital satisfaction.⁹

• Try to empathize and understand what might be bothering your spouse.

• Practice emotional regulation techniques such as diaphragmatic breathing and time-out to prevent fights from escalating; meditation has also been found to improve emotional regulation.^10,11

• Ask your spouse to come to the office to discuss relationship issues. A possible script: “I saw our doctor today and was asked about relationship problems. Based on what I shared, our doctor recommended that you come in with me next time so that both sides of the story can be heard and recommendations could be made to help us. Would you consider going with me?” Alternatively, ask your spouse to consider couple therapy.

Sexual Libido Incongruities

• Accept that differences in libido exist, including that a man's libido is sometimes less than a woman's libido.

• Schedule sex on the same night every week.

Lack of Trust and Communication

• Set aside time to talk without distractions (e.g., talking while walking, putting cell phones away during dinner).

• Ask your spouse to express what is really bothersome by using I statements (e.g., I feel angry when you…).

• Watch a relationship-oriented movie together; research shows that couples who watch and discuss relationship movies on a regular basis are less likely to divorce¹² (e.g., The Story of Us [1999], Hope Springs [2012]).

• Increase your involvement in activities that promote connection, including novel activities that have benefit in facilitating connection (e.g., riding motorized scooters to have dinner in a previously unvisited restaurant).¹³

• Read books about marriage; bibliotherapy is an effective intervention for a variety of psychological problems^14,15 (e.g., Hold Me Tight by Susan Johnson, The Seven Principles for Making Marriage Work by John Gottman and Nan Silver, The Sex-Starved Marriage by Michele Weiner Davis).

• See a licensed marriage therapist; therapists who practice Emotionally Focused Couple Therapy typically provide the best outcome.^16,17

RED FLAG REFERRALS

Substance abuse, infidelity, high levels of contempt, or intimate partner violence indicate the need for specific referrals (i.e., addiction treatment center, couple therapy, anger management therapy, women's shelter, respectively). Physicians should follow safety protocols if exposure to volatile patients is an issue.

Case Resolution

The physician in the case scenario should recommend that the patient have a conversation with her husband and suggest to him that they have a scheduled date night once a week. The patient could be encouraged to read a book on marital health or sexuality and to engage in more fun activities with her husband on a regular basis. She should be encouraged to come back in a month to report whether the situation has improved. If it has not improved, the physician should offer a referral to a qualified couple therapist.

The authors thank Dave Slawson, MD, for his expert assistance in developing this article.