Further experience in conjoint psychotherapy of marital pairs ALAN M. MANN,* MD; FREDERICK W. LUNDELL,t MD
Conjoint therapy of marital partners is a technique that lends itself to the counselling efforts of health professionals. Its growing use has, however, brought with it seemingly inevitable pitfalls, such as inadequate assessment of individual needs and psychopathology, overzealous application and disregard of certain contraindications, management problems and goal definition that may be unclear to patients or more related to the therapist's personality than to an objective view of the marriage dynamics. Despite the difficulties and pitfalls of this relatively new field, conjoint therapy can be the treatment of choice when the primary difficulties are related to the inability to cope in the marital situation, even though functioning in other social roles is adequate. La therapie de couple est une technique qul se pr.te aux efforts d'orientation matrimoniale quoffrent les professionnels de Ia sante. Toutefols, son emplol croissant a fait surgir des pieges apparemment inevitables, tels qu'une evaluation inadequate des besoins et de Ia psychopathologie des individus, une application intempestive et une insouciance a l'egard de certaines contreindications, des problemes d'organisation et une definition des objectifs qui peut paraitre obscure aux patients ou d'avantage reliee a Ia personnalite du therapeute qu'a une vue objective de Ia dynamique du manage. En depit des difficultes et des pieges de ce champ d'activite relativement nouveau, Ia th6rapie de couple peut .tre le traitement de choix quand les difficultes premieres sont reliees a une incapacite de faire face a Ia situation conjugale, malgre un fonctionnement adequat dans d'autres r8les sociaux.
From the Montreal General Hospital and
McGill University, Montreal *Psycl..jatnst..jn..cl.jef, The Montreal General Hospital and professor of psychIatry, McGill University tChief of service, psychIatry, Queen Mary Veterans' Hospital, Montreal and associate professor of psychiatry, McGill University Reprint requests to: Dr. Alan M. Mann. Psychiatrist-in-chief, The Montreal General Hospital, 1650 Cedar Ave., Montreal, PQ H3G 1A4
The conjoint treatment of marital partners has, like family therapy, become popular in a relatively short time.1 Seeing the marital partners as a unit is now commonly recommended in centres dealing with the overall psychosocial assessment of medical problems, and conjoint therapy might prove of particular importance for family practitioners if it offered a more reliable method of counselling. Earlier we2'3 noted that, as a therapeutic technique, conjoint therapy seemed an improvement over the individual approaches standard at the time. Further experience has tended to confirm our earlier findings, but it has also uncovered certain problems and pitfalls that appear inherent in this form of therapy. In this communication we examine certain aspects of these problems as they may affect the work of the therapist. Problems in conjoint therapy The difficulties encountered in conjoint therapy may conveniently be conceptualized under the following headings: 1. Inadequate assessment of the relationship between symptoms and marital dynamics. 2. Failure to recognize contraindications - diagnostic and situational. 3. Management problems - situational and related to the personality of the therapist. 4. Problems of goal definition. Although these difficulties have here been enumerated separately, in practice they are interwoven and overlapping. Inadequate assessment This represents the largest group of difficulties. They stem from the therapist's having chosen conjoint therapy without having fully evaluated the proper diagnosis of the individual patient and the relation of individual psychopathology to the interaction of the two persons involved. Some emotional problems are totally unrelated to the marital situation itself; others may touch only tangentially on the marriage. Therefore, before undertaking conjoint therapy the therapist should thoroughly assess the strengths and weaknesses of the marital partner first referred to him, quite apart from evaluating the marital dynamics.
772 CMA JOURNAL/APRIL 9, 1977/VOL. 116
Diagnostic and situational contraindications In our experience, conjoint therapy has not been helpful in persons represented in any of the following diagnostic groups: a) the rigid obsessive-compulsive personality; b) the withdrawn, schizoid individual; c) the passiveaggressive personality; and d) the paranoid psychotic. Certain situations also militate against conjoint therapy: a) determined and repeated refusal to involve the partner; b) mutual reinforcement of neurotic needs; c) the presence of "secret knowledge" (i.e., data known to the therapist and only one of the partners); and d) when conjoint therapy is merely part of a ritual, as in confirming one partner's beliefs regarding the other, use of the therapist as a confirmatory agent for the wish to divorce, and determination by one partner to preserve the status quo at all costs. Two case reports illustrate two examples of such contraindications - the schizoid personality and the refusal to involve the partner.
Case reports Case 1
A young woman was being treated for many chronic somatic symptoms of anxiety. Her husband attended early on. In therapy, the classic picture was noted. The husband, a man with many schizoid traits, responded to the conjoint situation in the same manner as he had to the marital and other situations - through withdrawal and nonparticipation. As an example, on one occasion, just as the wife was attempting to focus on the problem of communication, the husband - a student - took vp one of his textbooks and started to read. Repeated interventions by the therapist did not change the husband.s defensive maneuvers. With a marital partner of this kind, one should embark on individual therapy with the first partnt.r
before attempting, with conjoint therapy, to deal with the way in which the schizoid character of the partner impinges on the
overall marital relationship. Case 2 A 38-year-old woman who was being treated for depression had many vindictive complaints about her husband's lack of understanding and other faults. The therapist, thinking it would be sound to see the couple together, attempted to overcome the patient's steadfast refusal to
agree to conjoint therapy. Eventually an appointment was arranged. The husband appeared punctually; the wife was not present. After a telephone call, the wife joined the husband and therapist in the office 20 minutes late. The therapist attempted without success to discuss the material the wife had presented at earlier sessions. After 15 minutes, the wife said that she had "had enough" and stalked out of the office. She later telephoned to tell the therapist that he would not be bothered with her again, and that she had told him therapy would not work; she then took an overdose of a drug and had to be admitted to hospital. The overdosage seemed an obvious attempt to avenge herself on the therapist for what she perceived as a devastating humiliation. This patient was delivering a serious message, despite the nonlethality of her overdose; never again have we been this insistent or forceful in arranging conjoint sessions. Management problems Once conjoint therapy is undertaken some problems are linked to situations; others centre around the personality of the therapist.
Related to situations A most difficult problem is the situation in which the therapist and one of the marital partners share certain facts not yet known to the other partner. Most commonly the information pertains to sexual infidelity, but this is not necessarily the only area of unilateral secrecy - business and financial problems can also be involved. In the latter instance, if the other partner were to know of these facts and use them in a vindictive manner, serious socioeconomic consequences could result for the "offending" individual. Therapists have few guidelines in managing these situations. There seems to be a fundamental difference of opinion between those who insist that everything should be brought into the open and those who hold that such matters should not be allowed to emerge until a favourable working alliance has been created (and that even then the timing is exceedingly delicate). With hidden knowledge, the atmosphere of the sessions can certainly be unbalanced; premature revelation of material of this nature may do irreparable harm to an already fragile marital alliance. There is a strong argument in favour of eventual full disclosure, based on the fact that, if the partner knew of the "secret", it would help explain the behaviour and attitude of the other partner. A classic example is that of a woman who may blame herself for her husband's protracted lack of sexual interest in her, whereas in fact the husband is struggling with guilt about his infidelity. He may
project these feelings onto his wife in the form of irritability and complaints, or may retreat completely from sexual activity because of a feared inability to perform. This in turn worsens the original situation. In our experience, these situations have been satisfactorily resolved only when the partners are working hard at understanding each other, not only during the session but also in the interval between sessions. In so doing, as the meaningfulness of their communication increases, the "secret" can be brought out in an atmosphere of trust between therapist and couple. In practice, we have often found that if the "innocent" partner is really attuned to the marriage he or she may sense that the spouse is having an extramarital affair. The real problem then becomcs whether the "victim" allows him- or herself to admit this consciously. A second difficult problem is that of the scapegoat phenomenon. In managing conjoint therapy, messages are often misunderstood. If one notes a tendency for one partner to say or imply "I told you so" just after leaving the office, one must take immediate steps to deal with this. This remark almost inevitably is a signal that one party perceives an alliance between the therapist and the other party. Furthermore, it is likely that the recipient of the remark feels bullied, squeezed or pushed by therapist or spouse. In this situation, a useful device is to record a full session and then play all or part of it back at the next meeting. By this means all concerned have a better idea of what the therapist is actually trying to convey. This is also useful for the therapist who might have inadvertently said or done something to create this impression.
Related to the therapist's personality Regardless of the situational pitfalls, it seems clear that many of the problems inherent in conjoint marital therapy have their root in the therapist's own personality. For example, excessive therapeutic zeal is a common problem, as are idiosyncratic interpretation of marital roles and overidentification with one of the marital partners. In regard to overidentification, if the therapist unwittingly becomes the advocate of one of the partners he can no longer act in an objective and unbiased role, and this will &indoubtedly affect his judgement and interpretation of the overall situation. The therapist should be alert enough to recognize when he is being used as a vehicle for the justification of a predetermined decision on the part of one of the partners. A common problem related to per-
sonality is that a therapist's judgement and personal experience may not be relevant to contemporary concepts of marriage. This may arise when there is an age gap between therapist and patient, or a strongly held religious difference. Problems of goal definition Goal definition in marital therapy is another area in which variations in the therapist's training and individual differences between the personal lifestyle and perception of contemporary marital phenomena come into play. First of all, one should accept the reality that there is no one true or "revealing" way of handling conjoint therapy. There are many different forms and approaches; a one-sided dogmatic theoretical approach is quite unsound. Goal setting clearly must be based on the consensus of both partners. One pitfall in this area is the therapist's failure to concentrate sufficiently on goals from the couple's point of view. It is only reasonable that both the referring physician and the marital pair should have an opportunity to ascertain and discuss the approach that the conjoint therapist intends to use. A clear, common-sense explanation of what the therapist is aiming at should be presented early on. The couple should have an opportunity to work this through and decide whether they agree with the therapist's goals and viewpoint. These therapeutic goals may range from production of insightful awareness of underlying unconscious drives,4 with little or no reference to problemsolving on the one extreme, to a problem-oriented, shorter approach dictated by the interest of practicality on the other. The problem-oriented approach consists of allowing the couple to see how their interaction creates and perpetuates yet could potentially solve the problems between them. Such an approach does not necessarily provide insight into deeper personality conflicts. It does, however, require a much livelier participation by the therapist. Even so, some situations are so difficult they cannot be endured by normal people without serious disruption of behaviour or symptom formation; to attempt to reconcile a person to such an impossible situation may not only be fatuous but actually harmful. The total problem may be insoluble. In defining goals, certain questions must be explored: 1. What did the couple initially expect from marriage? 2. How realistic is their perception of marriage in relation to their social, cultural and religious pressures?
CMA JOURNAL/APRIL 9, 1977/VOL. 116 773
3. What do they consider to be an acceptable relationship in the here and now? For example, are they consulting the therapist simply in order not to break with their children, or are they really looking for a more adequate and happier adjustment? In goal-setting, perhaps the key factor for the therapist is that he may be trying to uncover and deal with deepseated feelings, mutual misperceptions and bitter memories, some of which might be much better left in the background and not dealt with at all. Discussion The growing use of the technique of conjoint therapy of marital partners has brought with it the inevitable concomitants of every new wave - in psychiatry - an initial overenthusiasm followed by a compensatory reaction, then a period of consolidation.5 We believe that the practice of dealing with certain aspects of human unhappiness that have their roots in the marital relationship by seeing the' partners together is worth while, though it may be fraught with pitfalls. Even if the therapist elects not to pursue conjoint therapy we recommend that anyone conducting counselling have at least one session in which the marital partners are seen together. This at least introduces another dimension into the therapeutic situation and tends to reduce observer error and other difficulties alluded to earlier.2 Conjoint therapy does have pitfalls, and overzealous application of conjoint techniques without proper assessment of the individual needs and individual psychopathology can be deleterious. Furthermore, with management problems that involve inflexibility, duplicity, collusion and self-perpetuating
The urinary temperature and factitious fever The differential diagnosis of fever of unknown origin sometimes includes factitious, or spurious, fever. Patients may be quite ingenious at "cooking" the body temperature, and the diagnosis of factitious fever may be difficult to make. Double-checking the temperature of freshly voided urine has been suggested as the solution. A recent study in the New England Journal of Medicine (296: 23, 1977) by H.W. Murray and colleagues confirms what has been found by others (e.g., C. Ellenbogen and B. M. Nord [JAMA 219: 912, 1972]) - urinary temperatures are consistently within 1
patterns of behaviour, this technique should be pursued with considerable caution. An essential part of the early encounters between therapist and couple should be the definition of the goals of therapy. Even earlier than this should come time spent on assessment of the psychopathology of the individual and the relation of this to the marital situation. Despite all these difficulties and perhaps inevitable pitfalls, conjoint therapy of marital pairs can be the treatment of choice for many situations. This is especially the case when the primary difficulties are related to inability to cope with the marital situation, despite relatively adequate functioning in other social and cultural roles. With a proper recognition of its limitations and shortcomings, conjoint therapy offers for the primary physician and for other health professionals involved in counselling an opportunity for intervention and a briefer and more helpful mode than traditional one-to-one relationships. In conducting conjoint therapy, however, therapists would do well to remember the old adage, "There are always three sides to a story; his side, her side and the real side." References 1. HALEY J: Whither family therapy? Fain Proc 1: 69, 1962 2. MANN AM, LUNDELL EW: Psychotherapy of marital partners: a critique and re.evaluatson. Can Psychiatr Assoc .! 9: 313, 1964 3. LUNDELL FW, MANN AM: Conjoint psychotherapy of marital pairs. Can Med Assoc .1 94: 542, 1966 4. ALDOUS NR: Mechanisms of stalemate in conjoint marital therapy. Can Psychaatr AsSoc 1 18: 191, 1973 5. DUNHAM HW: Community psychiatry: the newest therapeutic bandwagon. Arch Gen Psychiatry 12: 303, 1965
to 1.S0C of simultaneously measured oral temperatures. A nomogram can easily be constructed to relate the two; the correlation is good. Murray and associates, by measuring oral and urinary temperatures in normal volunteers and patients with febrile illnesses, have found that a urinary temperature below the 99% confidence limit for the recorded oral temperature is essentially diagnostic of factitious fever. Measuring the urinary temperature is simple, especially with electronic thermometers, and can be done unobstrusively. Moral: modern medical Munchausens must move more meticulously; medics may master Machiavellian malingerers. U
774 CMA JOURNAL/APRIL 9, 1977/VOL. 116
FOR ANALGESIC ACTIVITY 0292* Tablets 0222*Tablets INDICATIONS: For relief of mild to moderate pain, fever and inflammation as in influenza, common cold, low back and neck pain, headache, trauma, following dental and surgical procedures. DOSAGE: 222*.AduIts.1 or 2 tablets one to three times daily; Children's dosage, when recommended byaphysician:lOto 14 years, one tablet, one to three times daily; 5 to 10 years, one-half tablet, one to three times daily; 292*. Adults-i tablet two to three times daily. CONTRAINDICATIONS: Gastrointestinal ulceration and sensitivity to any of the components. WARNINGS: Salicylates increase the effects of anticoagulants. Caution is necessary when salicylates and anticoagulants are prescribed concurrently. Also, salicylates may depress the concentration of prothrombin in the plasma. Large doses of salicylates may affect insulin requirements of diabetics. Salicylates may potentiate sulfonylurea hypoglycemic agents. Analgesic abuse (excessive and prolonged therapy) has been associated with nephropathy. TO AVOID ACCIDENTAL POISONING ACETYLSALICYLIC ACID PREPARATIONS MUST BE KEPT WELL OUT OF REACH OF CHILDREN. PRECAUTIONS: Give with caution to patients with asthma, other allergic conditions, bleeding tendencies, or hypoprothrombinemia. Salicylates can produce changes in thyroid function tests. Observe care in use of codeine, although tolerance and addiction are rare. Give codeine with caution to patients with severe respiratory depression. Its depressant effect may be enhanced by concurrent administration of sedatives and tranquilizers. ADVERSE REACTIONS: Ac.tyis.ilcyiIc acid: Gastrointestinal: dyspepsia, heartburn, nausea, vomiting, diarrhea, gastrointestinal ulceration and bleeding. Ear reactions: tinnitus, hearing loss. Hematoiogic: anemia, leukopenia, thrombocytopenia, purpura. Dermatologic and Hypersensitivity: urticaria, angioedema, pruritus, various skin eruptions, asthma and anaphylaxis. Miscellaneous: mental confusion, drowsiness, sweating and thirst. Cedelne: Average or large doses may cause various gastrointestinal symptoms such as nausea, vomiting and constipation. Caffeine: May cause nausea, nervousness, insomnia, headache, vomiting, palpitation, vertigo, muscle tremor, sensory disturbances, excessive diuresis in sensitive patlents. Large doses may cause gastric ulceration. FULL INFORMATION AVAILABLE ON REQUEST HOW SUPPLIED 0292* Tablets - Peach, 0 marked, scored, engraved 292 on one side. Each tablet contains: acetylsalicylic acid 375 mg, caffeine citrate 30 mg, codeine phosphate 30 mg. Available in bottles of 50 and 500. 0222* Tablets - White, scored, engraved 222 on one side. Each tablet contains: acetylsalicylic acid 375 mg, caffeine citrate 30 mg, codeine phosphate 8 mg. Available in tubes of 12; bottles of 40 and 100; also bottles of 60 with safety cap.
FOUNDED IN CANADA IN 1899
________
CNARI.E5 3. PROSET & CO. KIRKLAND (MONTREAL) CANADA
IRMACI
Trademark (MC-387a)
Conjoint therapy of marital partners is a technique that lends itself to the counselling efforts of health professionals. Its growing use has, however, brought with it seemingly inevitable pitfalls, such as inadequate assessment of individual needs and psychopathology, overzealous application and disregard of certain contraindications, management problems and goal definition that may be unclear to patients or more related to the therapist's personality than to an objective view of the marriage dynamics. Despite the difficulties and pitfalls of this relatively new field, conjoint therapy can be the treatment of choice when the primary difficulties are related to the inability to cope in the marital situation, even though functioning in other social roles is adequate. La therapie de couple est une technique qul se pr.te aux efforts d'orientation matrimoniale quoffrent les professionnels de Ia sante. Toutefols, son emplol croissant a fait surgir des pieges apparemment inevitables, tels qu'une evaluation inadequate des besoins et de Ia psychopathologie des individus, une application intempestive et une insouciance a l'egard de certaines contreindications, des problemes d'organisation et une definition des objectifs qui peut paraitre obscure aux patients ou d'avantage reliee a Ia personnalite du therapeute qu'a une vue objective de Ia dynamique du manage. En depit des difficultes et des pieges de ce champ d'activite relativement nouveau, Ia th6rapie de couple peut .tre le traitement de choix quand les difficultes premieres sont reliees a une incapacite de faire face a Ia situation conjugale, malgre un fonctionnement adequat dans d'autres r8les sociaux.
From the Montreal General Hospital and
McGill University, Montreal *Psycl..jatnst..jn..cl.jef, The Montreal General Hospital and professor of psychIatry, McGill University tChief of service, psychIatry, Queen Mary Veterans' Hospital, Montreal and associate professor of psychiatry, McGill University Reprint requests to: Dr. Alan M. Mann. Psychiatrist-in-chief, The Montreal General Hospital, 1650 Cedar Ave., Montreal, PQ H3G 1A4
The conjoint treatment of marital partners has, like family therapy, become popular in a relatively short time.1 Seeing the marital partners as a unit is now commonly recommended in centres dealing with the overall psychosocial assessment of medical problems, and conjoint therapy might prove of particular importance for family practitioners if it offered a more reliable method of counselling. Earlier we2'3 noted that, as a therapeutic technique, conjoint therapy seemed an improvement over the individual approaches standard at the time. Further experience has tended to confirm our earlier findings, but it has also uncovered certain problems and pitfalls that appear inherent in this form of therapy. In this communication we examine certain aspects of these problems as they may affect the work of the therapist. Problems in conjoint therapy The difficulties encountered in conjoint therapy may conveniently be conceptualized under the following headings: 1. Inadequate assessment of the relationship between symptoms and marital dynamics. 2. Failure to recognize contraindications - diagnostic and situational. 3. Management problems - situational and related to the personality of the therapist. 4. Problems of goal definition. Although these difficulties have here been enumerated separately, in practice they are interwoven and overlapping. Inadequate assessment This represents the largest group of difficulties. They stem from the therapist's having chosen conjoint therapy without having fully evaluated the proper diagnosis of the individual patient and the relation of individual psychopathology to the interaction of the two persons involved. Some emotional problems are totally unrelated to the marital situation itself; others may touch only tangentially on the marriage. Therefore, before undertaking conjoint therapy the therapist should thoroughly assess the strengths and weaknesses of the marital partner first referred to him, quite apart from evaluating the marital dynamics.
772 CMA JOURNAL/APRIL 9, 1977/VOL. 116
Diagnostic and situational contraindications In our experience, conjoint therapy has not been helpful in persons represented in any of the following diagnostic groups: a) the rigid obsessive-compulsive personality; b) the withdrawn, schizoid individual; c) the passiveaggressive personality; and d) the paranoid psychotic. Certain situations also militate against conjoint therapy: a) determined and repeated refusal to involve the partner; b) mutual reinforcement of neurotic needs; c) the presence of "secret knowledge" (i.e., data known to the therapist and only one of the partners); and d) when conjoint therapy is merely part of a ritual, as in confirming one partner's beliefs regarding the other, use of the therapist as a confirmatory agent for the wish to divorce, and determination by one partner to preserve the status quo at all costs. Two case reports illustrate two examples of such contraindications - the schizoid personality and the refusal to involve the partner.
Case reports Case 1
A young woman was being treated for many chronic somatic symptoms of anxiety. Her husband attended early on. In therapy, the classic picture was noted. The husband, a man with many schizoid traits, responded to the conjoint situation in the same manner as he had to the marital and other situations - through withdrawal and nonparticipation. As an example, on one occasion, just as the wife was attempting to focus on the problem of communication, the husband - a student - took vp one of his textbooks and started to read. Repeated interventions by the therapist did not change the husband.s defensive maneuvers. With a marital partner of this kind, one should embark on individual therapy with the first partnt.r
before attempting, with conjoint therapy, to deal with the way in which the schizoid character of the partner impinges on the
overall marital relationship. Case 2 A 38-year-old woman who was being treated for depression had many vindictive complaints about her husband's lack of understanding and other faults. The therapist, thinking it would be sound to see the couple together, attempted to overcome the patient's steadfast refusal to
agree to conjoint therapy. Eventually an appointment was arranged. The husband appeared punctually; the wife was not present. After a telephone call, the wife joined the husband and therapist in the office 20 minutes late. The therapist attempted without success to discuss the material the wife had presented at earlier sessions. After 15 minutes, the wife said that she had "had enough" and stalked out of the office. She later telephoned to tell the therapist that he would not be bothered with her again, and that she had told him therapy would not work; she then took an overdose of a drug and had to be admitted to hospital. The overdosage seemed an obvious attempt to avenge herself on the therapist for what she perceived as a devastating humiliation. This patient was delivering a serious message, despite the nonlethality of her overdose; never again have we been this insistent or forceful in arranging conjoint sessions. Management problems Once conjoint therapy is undertaken some problems are linked to situations; others centre around the personality of the therapist.
Related to situations A most difficult problem is the situation in which the therapist and one of the marital partners share certain facts not yet known to the other partner. Most commonly the information pertains to sexual infidelity, but this is not necessarily the only area of unilateral secrecy - business and financial problems can also be involved. In the latter instance, if the other partner were to know of these facts and use them in a vindictive manner, serious socioeconomic consequences could result for the "offending" individual. Therapists have few guidelines in managing these situations. There seems to be a fundamental difference of opinion between those who insist that everything should be brought into the open and those who hold that such matters should not be allowed to emerge until a favourable working alliance has been created (and that even then the timing is exceedingly delicate). With hidden knowledge, the atmosphere of the sessions can certainly be unbalanced; premature revelation of material of this nature may do irreparable harm to an already fragile marital alliance. There is a strong argument in favour of eventual full disclosure, based on the fact that, if the partner knew of the "secret", it would help explain the behaviour and attitude of the other partner. A classic example is that of a woman who may blame herself for her husband's protracted lack of sexual interest in her, whereas in fact the husband is struggling with guilt about his infidelity. He may
project these feelings onto his wife in the form of irritability and complaints, or may retreat completely from sexual activity because of a feared inability to perform. This in turn worsens the original situation. In our experience, these situations have been satisfactorily resolved only when the partners are working hard at understanding each other, not only during the session but also in the interval between sessions. In so doing, as the meaningfulness of their communication increases, the "secret" can be brought out in an atmosphere of trust between therapist and couple. In practice, we have often found that if the "innocent" partner is really attuned to the marriage he or she may sense that the spouse is having an extramarital affair. The real problem then becomcs whether the "victim" allows him- or herself to admit this consciously. A second difficult problem is that of the scapegoat phenomenon. In managing conjoint therapy, messages are often misunderstood. If one notes a tendency for one partner to say or imply "I told you so" just after leaving the office, one must take immediate steps to deal with this. This remark almost inevitably is a signal that one party perceives an alliance between the therapist and the other party. Furthermore, it is likely that the recipient of the remark feels bullied, squeezed or pushed by therapist or spouse. In this situation, a useful device is to record a full session and then play all or part of it back at the next meeting. By this means all concerned have a better idea of what the therapist is actually trying to convey. This is also useful for the therapist who might have inadvertently said or done something to create this impression.
Related to the therapist's personality Regardless of the situational pitfalls, it seems clear that many of the problems inherent in conjoint marital therapy have their root in the therapist's own personality. For example, excessive therapeutic zeal is a common problem, as are idiosyncratic interpretation of marital roles and overidentification with one of the marital partners. In regard to overidentification, if the therapist unwittingly becomes the advocate of one of the partners he can no longer act in an objective and unbiased role, and this will &indoubtedly affect his judgement and interpretation of the overall situation. The therapist should be alert enough to recognize when he is being used as a vehicle for the justification of a predetermined decision on the part of one of the partners. A common problem related to per-
sonality is that a therapist's judgement and personal experience may not be relevant to contemporary concepts of marriage. This may arise when there is an age gap between therapist and patient, or a strongly held religious difference. Problems of goal definition Goal definition in marital therapy is another area in which variations in the therapist's training and individual differences between the personal lifestyle and perception of contemporary marital phenomena come into play. First of all, one should accept the reality that there is no one true or "revealing" way of handling conjoint therapy. There are many different forms and approaches; a one-sided dogmatic theoretical approach is quite unsound. Goal setting clearly must be based on the consensus of both partners. One pitfall in this area is the therapist's failure to concentrate sufficiently on goals from the couple's point of view. It is only reasonable that both the referring physician and the marital pair should have an opportunity to ascertain and discuss the approach that the conjoint therapist intends to use. A clear, common-sense explanation of what the therapist is aiming at should be presented early on. The couple should have an opportunity to work this through and decide whether they agree with the therapist's goals and viewpoint. These therapeutic goals may range from production of insightful awareness of underlying unconscious drives,4 with little or no reference to problemsolving on the one extreme, to a problem-oriented, shorter approach dictated by the interest of practicality on the other. The problem-oriented approach consists of allowing the couple to see how their interaction creates and perpetuates yet could potentially solve the problems between them. Such an approach does not necessarily provide insight into deeper personality conflicts. It does, however, require a much livelier participation by the therapist. Even so, some situations are so difficult they cannot be endured by normal people without serious disruption of behaviour or symptom formation; to attempt to reconcile a person to such an impossible situation may not only be fatuous but actually harmful. The total problem may be insoluble. In defining goals, certain questions must be explored: 1. What did the couple initially expect from marriage? 2. How realistic is their perception of marriage in relation to their social, cultural and religious pressures?
CMA JOURNAL/APRIL 9, 1977/VOL. 116 773
3. What do they consider to be an acceptable relationship in the here and now? For example, are they consulting the therapist simply in order not to break with their children, or are they really looking for a more adequate and happier adjustment? In goal-setting, perhaps the key factor for the therapist is that he may be trying to uncover and deal with deepseated feelings, mutual misperceptions and bitter memories, some of which might be much better left in the background and not dealt with at all. Discussion The growing use of the technique of conjoint therapy of marital partners has brought with it the inevitable concomitants of every new wave - in psychiatry - an initial overenthusiasm followed by a compensatory reaction, then a period of consolidation.5 We believe that the practice of dealing with certain aspects of human unhappiness that have their roots in the marital relationship by seeing the' partners together is worth while, though it may be fraught with pitfalls. Even if the therapist elects not to pursue conjoint therapy we recommend that anyone conducting counselling have at least one session in which the marital partners are seen together. This at least introduces another dimension into the therapeutic situation and tends to reduce observer error and other difficulties alluded to earlier.2 Conjoint therapy does have pitfalls, and overzealous application of conjoint techniques without proper assessment of the individual needs and individual psychopathology can be deleterious. Furthermore, with management problems that involve inflexibility, duplicity, collusion and self-perpetuating
The urinary temperature and factitious fever The differential diagnosis of fever of unknown origin sometimes includes factitious, or spurious, fever. Patients may be quite ingenious at "cooking" the body temperature, and the diagnosis of factitious fever may be difficult to make. Double-checking the temperature of freshly voided urine has been suggested as the solution. A recent study in the New England Journal of Medicine (296: 23, 1977) by H.W. Murray and colleagues confirms what has been found by others (e.g., C. Ellenbogen and B. M. Nord [JAMA 219: 912, 1972]) - urinary temperatures are consistently within 1
patterns of behaviour, this technique should be pursued with considerable caution. An essential part of the early encounters between therapist and couple should be the definition of the goals of therapy. Even earlier than this should come time spent on assessment of the psychopathology of the individual and the relation of this to the marital situation. Despite all these difficulties and perhaps inevitable pitfalls, conjoint therapy of marital pairs can be the treatment of choice for many situations. This is especially the case when the primary difficulties are related to inability to cope with the marital situation, despite relatively adequate functioning in other social and cultural roles. With a proper recognition of its limitations and shortcomings, conjoint therapy offers for the primary physician and for other health professionals involved in counselling an opportunity for intervention and a briefer and more helpful mode than traditional one-to-one relationships. In conducting conjoint therapy, however, therapists would do well to remember the old adage, "There are always three sides to a story; his side, her side and the real side." References 1. HALEY J: Whither family therapy? Fain Proc 1: 69, 1962 2. MANN AM, LUNDELL EW: Psychotherapy of marital partners: a critique and re.evaluatson. Can Psychiatr Assoc .! 9: 313, 1964 3. LUNDELL FW, MANN AM: Conjoint psychotherapy of marital pairs. Can Med Assoc .1 94: 542, 1966 4. ALDOUS NR: Mechanisms of stalemate in conjoint marital therapy. Can Psychaatr AsSoc 1 18: 191, 1973 5. DUNHAM HW: Community psychiatry: the newest therapeutic bandwagon. Arch Gen Psychiatry 12: 303, 1965
to 1.S0C of simultaneously measured oral temperatures. A nomogram can easily be constructed to relate the two; the correlation is good. Murray and associates, by measuring oral and urinary temperatures in normal volunteers and patients with febrile illnesses, have found that a urinary temperature below the 99% confidence limit for the recorded oral temperature is essentially diagnostic of factitious fever. Measuring the urinary temperature is simple, especially with electronic thermometers, and can be done unobstrusively. Moral: modern medical Munchausens must move more meticulously; medics may master Machiavellian malingerers. U
774 CMA JOURNAL/APRIL 9, 1977/VOL. 116
FOR ANALGESIC ACTIVITY 0292* Tablets 0222*Tablets INDICATIONS: For relief of mild to moderate pain, fever and inflammation as in influenza, common cold, low back and neck pain, headache, trauma, following dental and surgical procedures. DOSAGE: 222*.AduIts.1 or 2 tablets one to three times daily; Children's dosage, when recommended byaphysician:lOto 14 years, one tablet, one to three times daily; 5 to 10 years, one-half tablet, one to three times daily; 292*. Adults-i tablet two to three times daily. CONTRAINDICATIONS: Gastrointestinal ulceration and sensitivity to any of the components. WARNINGS: Salicylates increase the effects of anticoagulants. Caution is necessary when salicylates and anticoagulants are prescribed concurrently. Also, salicylates may depress the concentration of prothrombin in the plasma. Large doses of salicylates may affect insulin requirements of diabetics. Salicylates may potentiate sulfonylurea hypoglycemic agents. Analgesic abuse (excessive and prolonged therapy) has been associated with nephropathy. TO AVOID ACCIDENTAL POISONING ACETYLSALICYLIC ACID PREPARATIONS MUST BE KEPT WELL OUT OF REACH OF CHILDREN. PRECAUTIONS: Give with caution to patients with asthma, other allergic conditions, bleeding tendencies, or hypoprothrombinemia. Salicylates can produce changes in thyroid function tests. Observe care in use of codeine, although tolerance and addiction are rare. Give codeine with caution to patients with severe respiratory depression. Its depressant effect may be enhanced by concurrent administration of sedatives and tranquilizers. ADVERSE REACTIONS: Ac.tyis.ilcyiIc acid: Gastrointestinal: dyspepsia, heartburn, nausea, vomiting, diarrhea, gastrointestinal ulceration and bleeding. Ear reactions: tinnitus, hearing loss. Hematoiogic: anemia, leukopenia, thrombocytopenia, purpura. Dermatologic and Hypersensitivity: urticaria, angioedema, pruritus, various skin eruptions, asthma and anaphylaxis. Miscellaneous: mental confusion, drowsiness, sweating and thirst. Cedelne: Average or large doses may cause various gastrointestinal symptoms such as nausea, vomiting and constipation. Caffeine: May cause nausea, nervousness, insomnia, headache, vomiting, palpitation, vertigo, muscle tremor, sensory disturbances, excessive diuresis in sensitive patlents. Large doses may cause gastric ulceration. FULL INFORMATION AVAILABLE ON REQUEST HOW SUPPLIED 0292* Tablets - Peach, 0 marked, scored, engraved 292 on one side. Each tablet contains: acetylsalicylic acid 375 mg, caffeine citrate 30 mg, codeine phosphate 30 mg. Available in bottles of 50 and 500. 0222* Tablets - White, scored, engraved 222 on one side. Each tablet contains: acetylsalicylic acid 375 mg, caffeine citrate 30 mg, codeine phosphate 8 mg. Available in tubes of 12; bottles of 40 and 100; also bottles of 60 with safety cap.
FOUNDED IN CANADA IN 1899
________
CNARI.E5 3. PROSET & CO. KIRKLAND (MONTREAL) CANADA
IRMACI
Trademark (MC-387a)
