Marital Counseling for the Obstetrician-Gynecologist

Marriage is a central life experience for about 90% of adults. While statistics report a declining trend in legal unions, Americans continue to marry and about 75% of Americans remarry.¹ In addition to those who enter legal marital unions, there is an increase in the number of unmarried, cohabiting couples.^{2, 3} These unions share many of the same 'couple' issues as married partners.

Marriage has far-reaching effects on health and well-being.  Episodes of distress and discord are part of normal human relationships, and discord, itself, need not be a threat. However, statistics on domestic violence^{4, 5, 6} and divorce,^{1, 7, 8} and a substantial literature on the pervasive effects of marital conflict on children,^{7, 9, 10} point out the destructive outcome of unresolved marital conflict.

The need for early intervention and treatment, and the efficacy of such treatment upon outcome variables for illness is well accepted. Effective early intervention may be as 'simple' as giving the patient permission to voice her concerns to a compassionate, caring professional or giving her correct information to dispel myths and misconceptions. The respect and validation received as a result of being heard may be enough to empower the patient before conflict becomes fixed or destructive.  The obstetrician-gynecologist can initiate a first level of treament by giving patients the opportunity to discuss concerns in an atmostphere of supportive listening.

Physicians, viewed by patients as authorities—available, confidential, and resourceful—are in an excellent position to offer brief marital counseling and intervention. Women may be able to visit a physician when their circumstances would not permit contact with a marriage or family therapist or even a minister.

The obstetrician-gynecologist has traditionally occupied the central medical position in the lives of many women. For women managing multiple roles (e.g. career woman, wife, mother), the obstetrician-gynecologist may be the only health professional seen on a regular basis. Women caught in the web of violence may not have 'permission' to consult a physician apart from 'women's concerns'. Research has indicated that battered women tend to make the obstetrician-gynecologist the first, and sometimes the only, physician consulted.¹¹

The current trend toward the obstetrician-gynecologist as a primary care physician, along with pressure to view medicine within the framework of total health and well-being, widens the role of the obstetrician-gynecologist. Marital counseling is a timely and relevant topic. Primary care physicians are major providers of mental health care in the United States.¹²  A single, brief, session may be all the intervention necessary to address patient concerns.¹³  Marital counseling, using effective models designed for brief sessions, is a timely and relevant topic.  

In the role of primary care physician, questions about health and well-being, including sexual health, have not been viewed by the patient as intrusive, but as a mark of interest and expertise.¹⁴ Physicians who communicate compassion and interest to their patients encourage patient confidence and openness, qualities that are necessary to ensure that the patient is not only served but satisfied with such service.

This chapter is written from the conviction that interest in the marital and sexual concerns of the patient is an obvious, legitimate, and necessary response to the total health needs of patients. And further, the responsible practice of medicine requires attention to the significant effects of couple interaction on the health of patients.  Recognizing the constraints of medical practice which must be balanced with the needs of the patient, this chapter is designed to encourage and assist the obstetrician-gynecologist to move easily and competently into brief marital counseling.

Information about marriage, and the prevalence and effects of marital conflict, including its common causes, are discussed. Skills and techniques necessary for physicians to effectively address marital and sexual concerns in brief sessions are offered. Finally, models for marital and sexual counseling are provided.

Marriage is, at the same time, both a personal and a public bond. While marriage is intimate and private, the existence of a legal spouse, even if that person is absent, is a public boundary. Not only does the choice of a spouse demonstrate one's personal taste and ability to secure a desirable mate, it also defines relationships with other persons (family, friends, potential employers) and institutions (bank, school, government). Healthy marriages have certain characteristics in common with other healthy interpersonal relationships.  These include the ability to negotiate solutions and solve problems; an adequate tolerance for ambiguity; positive attributions regarding interaction and behavior; and outcomes to situations and problems of life that meet the needs of both persons.¹⁵ Problem solving skills, which include communication skills, the assumption of good will, and the attribution of good intentions to the partner are basic ingredients for success.

Contrary to some popular beliefs, a successful marital relationship need not be egalitarian in the sense that tasks, responsibilities, and rewards are evenly divided. Rather, it is the perception that personal needs are being met within the relationship that makes the difference between distress and nondistress. Perception is a key variable in cognitive definitions of events as stressful or nonstressful.^{16, 17, 18}

Research confirms that it is not differences between people or particular problem areas that couples encounter that are important for marital distress, but how the problems are handled.¹⁹ Couples who are able to resolve problems when conflicts develop have the best chance to develop a successful marriage with high marital quality and personal well-being that are linked to health.^{20, 21}

Marital Expectations

Marriage in the United States today is marked by high expectations. The marital partner is expected to be friend, lover, confidant, wage-earner, caregiver, 'equal' partner, and soul mate.³ In sharp contrast, men and women in earlier generations were assigned clear, often opposite, gender roles; each expected that the opposite sex would remain somewhat mysterious and separate.^{22, 23, 24}

At the same time that couples hold high expectations, they are aware of the pressures against  successful marriage.  An average of 33% of Americans have been divorced at least once, and that statistic maintains across ethnic, religious, political and philosophical categories; and 50% of remarriages end in divorce.^{1, 25} This awareness may negatively influence the level of marital commitment and further undermine feelings of competency and self-esteem when marital conflict is present.⁸

Stress in Marriage 

Patients who hold contemporary expectations about marriage and divorce are at potential risk for increased levels of stress, discord, and conflict. Disappointment, distress, anger, and perceived stress are normal responses to the violation of expectations. The mediating variables in whether or not conflict occurs appear to be how the couple handles stress, and what methods are used for stress reduction.²⁶

Stress may increase partners' needs for support while simultaneously decreasing the ability to support each other. Stress may be associated with negative mood states that adversely affect couple interaction. In addition, stress may impair cognitive ability, particularly the ability to focus outward on problem-solving, rather than inward on personal need and mood.  Finally, stress has profound effects on sexual relating.²⁷

In literature on stress and coping, one of the most widely considered resources for stress management is social support.^{16, 28, 29, 30} Social support is positively related to both increased optimism and proactive coping under stress.^{31, 32} The concerned and involved physician-counselor provides an accessible, direct resource for patients' social support, and indirectly for increased optimism and use of proactive coping skills.

Multiple Roles of Women

Multiple roles of women result in demands on health and well-being, even in the absence of conflict. Multiple roles are accompanied by details and demands that increase the potential for distress. Daily hassles have been positively correlated with lowered feelings of well-being and higher levels of stress.^{33, 34}The level of daily hassles has been shown to be a better predictor of concurrent and subsequent psychologic symptoms than major life events.³⁴

About 65% of women work outside their homes.  Of mothers with children under 18, 70.5% work outside the home, including 60% with children under age 3, and 75% of these mothers work full-time.³⁵ At the same time, women continue to have primary responsibility for the care of home and children in our culture. In assessing the context of a marriage, close attention should be given to the presence and demands of multiple roles.

Sexuality in Marriage

During the past 40 years, sexual attitudes, behaviors, and expectations have been influenced not only by sex researchers³⁶ but by the sexual revolution, the evolution of women's roles, the holistic health cause, and media promotion. The obstetrician-gynecologist relates to a practice population that is informed about sexuality, and has many more expectations than previous generations.

Physicians potentially are well-equipped to address sexual concerns with information about human sexual response;³⁶ sexual dysfunctions;^{37, 38} normalcy data concerning sexual behavior;^{39, 40, 41} and sexual aspects of life transitions, such as pregnancy,⁴² postpartum,⁴³ and menopause.⁴⁴

Individual ideas and values about appropriateness and correctness are learned first within early family and sociocultural contexts. Values and ideas are often unexplored, unarticulated, and sometimes unconscious, even though they may support strong opinions and feelings. Basic tasks in marriage include learning how to maintain personal autonomy; get personal needs met; and live in an interdependent, intimate relationship. When the personal ideas and values of one partner conflict with those of the other, understanding, articulation, and negotiation may be required.

Conflict in marriage commonly occurs over the following: gender issues (the demands and conflicts of roles ascribed or assumed within the relationship); loyalties (e.g. friends, in-laws, other family members, clubs); the use of money; power (who's in charge); children (presence and behavior of); privacy; inability or unwillingness to communicate; and sexual concerns.^{24, 45, 46, 47} A brief description of each area follows.

Gender

Conflict about gender occurs because partners hold differing definitions and expectations about differences between women and men, and what form these differences should have in the relationship.  Despite cultural changes, ideas about gender appropriateness continue to influence couple interaction. 

The statement “Men (or women) are supposed to do{_____} (or be or act)” expresses ideas and values about gender appropriateness. Examples of traditional words or phrases applied to women are: giving, caring, vulnerable, helpful, sensitive to the needs of others, eager to soothe hurt feelings, emotional, childlike, and dependent. In contrast, men have been described as self-reliant, independent, forceful, analytical, self-sufficient, dominant, competitive, ambitious, and strong.

Loyalties

Marriage is lived in a context that includes relationships past and present. “When we are by ourselves, everything is fine”, or “If other people would just leave us alone, we wouldn't have any problems” are statements that reflect loyalty conflicts. Loyalty conflicts often present as jealousy or possessiveness on the part of one partner.

Money

People place differing values on money. Money is a medium of exchange, and as such, it may represent many things including: love, power, self-esteem, security, time, gifts, independence, masculinity, corruption, or evil. When marital partners differ in their values about money, conflict is the inevitable result.⁴⁷

Power

Power conflicts may center on any of the other common issues in marriage (e.g. money, sex, loyalty). Power has to do with feelings of personal competency, self-esteem, and efficacy, and ultimately with survival. Personal power styles include: dominance, coercion, blaming, giving-in, and egalitarian.⁴⁵ Power issues are a significant source of stress and underlie much of the violence in relationships.⁴⁸

Children

Children may be a source of conflict for marital partners who are parents, or for those who are childless. Conflict over children may involve a variety of issues around the children themselves, such as needs, care, expense, behavior, privacy, and parenting styles. The presence of step-children may introduce an added dimension to the conflict.  In addition, quarreling about children may be safer for the married couple than quarreling about some more deeply felt concern, such as sexual dissatisfaction. Further, quarreling about children may be prompted by other problems, such as the distribution of power within the marriage, or loyalty conflicts that have not been resolved. For example, a father might insist on certain types of behavior, with which his wife does not agree—not for its own sake,but out of loyalty to his own father or mother.

Privacy

Privacy issues include personal space, time, thoughts, emotion, and personal property.⁴⁵ Partners may differ widely in their learned definitions of each of these areas and in their personal needs. A partner with a high need for personal space may feel smothered by a partner who does not maintain distance, while the other partner may feel rejected by the demand for privacy.

Communication

Of all the concerns that are expressed in marital counseling, communication is one of the most discussed. Conflict is usually over the inability or perceived unwillingness of one partner to communicate with the other. Initial communication problems may relate to differences in the basic personality variables of extroversion or introversion. There are a number of other possibilities as well. For example, the adage 'information is power' is a marital truism. The refusal to communicate may be one partner's attempt to be in charge or to keep the partner from being in charge. Lack of communication may represent lack of trust in the other partner, in the partner's ability to understand or sympathize, or to maintain confidentiality.

Sexual Problems

Sexual problems are a frequent source of marital conflict.^{15, 49, 50}  Sexual issues in marriage have a particularly individual, intimate, and pervasive valence.  Sexuality is a core element of self-identity.  Sexual conflict invokes feelings of personal inadequacy and lack of worthiness that may further diminish a person's ability to cope with stress and conflict. 

Common sexual concerns include: impaired sexual desire; vaginal dryness and associated dyspareunia; dissatisfaction over coital frequency; duration and quality of sex play; premature ejaculation; erectile dysfunction (impotence); orgasmic dysfunction; and concerns about sexual practices and various coital positions.^{49, 50, 51} Many sexual concerns reflect relationship issues, including role expectations. Conversely, marital discord may be a reflection of sexual problems.

Marital Conflict and the Physician

Patients caught in the experience of marital conflict may present repeatedly to the physician with a variety of somatic complaints such as recalcitrant fatigue; headache; a variety of menstrual complaints; various aches and pains; depressed mood; and a sense of helplessness or hopelessness. Since social conditioning for women in our culture encourages the repression of anger, such repression may present as anxiety, depression, or even guilt over perceived personal failure.

The absence of an identifiable organic cause can provoke frustration in the physician who is not alert to the presence of marital conflict and can reinforce the patient's sense of inadequacy and incompetency to deal with life events. There is also the possibility that anxiolytics or other drugs may be prescribed that treat symptoms, use financial resources, and offer no lasting remedy.

One woman is beaten every 10–18 seconds in the United States.  An estimated 5.3 million incidents of intimate partner violence occur each year, and 95% of all victims are women.⁶ Battering appears to be the single greatest cause of serious injury to women, accounting for more injuries than auto accidents, muggings, and rape combined. In addition, it is impossible to estimate the number of small and untreated injuries inflicted. INTIMATE PARTNER VIOLENCE IS AN OBSTETRICS AND GYNECOLOGIC EMERGENCY.  Fifty percent (50%) of murdered women are killed by a current or previous partner, and murder is among the five most common causes of death for women ages 15–34.  IT IS THE LEADING CAUSE OF MATERNAL MORTALITY.⁶ Between 3% and 17% of women report or acknowledge recurrent severe assaults during pregnancy.⁵² If data are summarized, some form of domestic violence occurs in the United States in one half of its homes at least once per year.⁶

Marital rape may be the most frequent type of sexual assault, and it is common in the battering situation.⁵³ The victim of marital rape suffers all the psychologic sequelae of rape and in addition, is the only rape victim who has to live intimately with her rapist. Further, the rape occurs in a setting where traditional, legal, and emotional bonds frequently make disclosure almost impossible. The trauma of marital rape surpasses that of rape by acquaintances or strangers. 

Battered women seek regular medical care,⁶ often from an obstetrician-gynecologist, but seldom with battering as the chief complaint.  Victims have a high rate and extensive range of gynecologic somatic symptoms and frequently suffer post-traumatic stress disorder in addition to actual physical injury.^{6, 53, 54} Studies have shown the failure of physicians to respond to the issue of domestic violence in 40–92% of instances, even when a protocol for response was in place.^{6, 55}

The responsible physician must consider the meaning of domestic violence statistics as represented in the lives of patients. Marital and sexual history taking is a powerful tool for intervention in this silent, often deadly, epidemic.

If the current divorce trend continues, a minority of children born in the 1990s (about 40%) will live with both biologic parents from birth to age 18. Another 30% will begin life with married parents who will later divorce. The remaining 30% will be born to an unmarried woman.⁵⁶ Many children in the latter two groups will experience several changes in household composition and several marital transitions from divorce to remarriage to divorce again. Many will spend time with the live-in lovers of their parents, grandparents, or a step-parent. Each of these realignments may be expected to include discord and conflict.²

A substantial body of literature addresses the developmental effects of marital conflict on children.^{7, 8, 9, 10} Negative effects include behavior problems, anxiety, depression, difficulties relating to peers, and difficulties in their own future dating and marriage relationships. Cummings and colleagues⁵⁷ report that children as young as 10 months of age have shown distress in situations of marital conflict.

Of special interest is the finding in these studies that the manner in which conflict is resolved is more important to the child than the presence of conflict. Parents who successfully resolve their conflicts provide powerful positive role models to their children.

Divorce is a fact of life in the 21st century.  Forty three percent (43%) of first marriages end in divorce within 15 years.  Divorce rates are highest among women and men under age 45.  These are also the peak ages for childbearing and rearing.  Among all American adults, more than one third (33%)  experience divorce.  About 75% of divorced adults remarry; about 50% of remarriages end in divorce.^{1, 25}

The distress and conflict in the lives of adults represented by these statistics is accompanied by dislocation, distress, and often chronic instability both for adults and for their dependent children.⁷  Without intervention, the problems that attend marriage, divorce, and remarriage will continue to be a permanent part of the lives of patients.  

A single model in which to view all the aspects of individual or marital life does not exist. However, the biopsychosocial model is a useful beginning for physicians.  This enduring  model, based upon the familiar medical model, consists of the biologic or biophysical, the psychologic, and the social dimensions of illness.^{58, 59}

The biologic system emphasizes structure, including the molecular substrate of disease and its effects on biologic function. The psychologic system emphasizes psychodynamic, motivational, and personality factors; the social system stresses cultural, environmental, and personality factors, and their effects on the expression and experience of illness.

Components of the three systems further include the following:

1. Biologic—sex chromosomes, anatomy (phenotype) and physiology, hormones, aging, illness, drugs, surgery
   
2. Psychologic—parent-child interaction, touching, nurturance and affection, socialization, sex role expectations, self-esteem, anxiety, depression, guilt, anger
   
3. Social—culture, ethnicity, world-view, locus of control, the dyad or relationship, cooperation and communication, conflict.
   

Limitations of the biopsychosocial model for marital counseling include the underemphasis of context, and a lack of attention to the roles of cognition and of personal spirituality.

Developmental psychologists contend that human development is embedded in context and cannot be adequately evaluated, apart from the contexts of the individual's life.   

Context may be defined as everything external to the individual's person. An ecological systems approach is useful for studying contexts moving from the microsystems to the macrosystem. Included in this approach are one's immediate context (family, workplace, peer group, classroom); the links between contexts (a parent-teacher conference); the larger sociocultural context; and the overarching context of public norms and policy (e.g. laws regarding lunches available for school children, regulations on abortion, divorce laws).

Knowledge of context provides information and clues for the physican and is invaluable for optimal diagnosis, treatment, and care.   

Cognition

Both external (behavioral) and internal (affective, cognitive) factors play roles in the development and maintenance of marital conflict.⁶⁰ Problem solving, including dealing with stressful events, requires cognitive processes.^{17, 18} Appraisal and attributions within the marital relationship are cognitive processes.¹⁷ The cognitive domain of development includes all the mental processes used to obtain knowledge or to become aware of the environment (perception, imagination, judgment, memory, language, processes used to think, decide, and learn, both formal and informal education, and the accumulated wisdom from life experience). Affective or emotional responses give valuable insight into both patient state and style.⁶¹

Spiritual

Religion as a formal socializing influence is included in the psychosocial domains of development and the biopsychosocial model. To be inclusive, however, the basic faith system that supports and shapes personal attitudes and behaviors may need to be examined in marital counseling. Personal religious beliefs affect all domains of life.⁶² The patient's personal faith system may operate apart from organized religion.

The biopsychosocial model with a broader definition of context and additional attention to the roles of cognition and spirituality provides excellent categories for viewing the total life and well-being of patients.

Effective counseling requires knowledge, comfort, and skill. It does not require multiple sessions to be effective.¹³ Physicians give medical counsel to patients routinely within the constraints of a normal practice.

Medical counsel and marital counseling by the physician differ significantly.  Medical counsel is offered from a wide base of knowledge and training, and the physician approaches the patient as an authority, clearly in control of the situation.  Information, knowledge, and training about marriage and marital concerns is not part of the medical education of most physicians, and the physician need not expect to treat marital and sexual problems and difficulties with the same depth of knowledge used to address other health concerns. 

Unlike the practice of medicine, counseling does not require the prescribing of the right answer to patients. On the contrary, an effective counselor enters the counseling situation with the fundamental belief that right answers will emerge as the patient is assisted to communicate her issues, clarify her needs and wants, and work out a plan for moving toward a desired result. In this sense, the physician is seen as a facilitator or enabler.   

This does not mean that marital counseling requires no specialized knowledge or skill. On the contrary, the more information the physician has about marriage and marital conflict, and the greater the knowledge of counseling skills, the better able she or he will be to participate fully in the experience of the patient. Excellent references on counseling skills are available for the beginning physician-counselor and should be used.^{63, 64, 65, 66}

Resource material is available on most issues that will arise during the counseling session.  Knowledge about issues will grow as answers to patient concerns are sought and the physician participates in on-going patient dialogue and problem solving.      

Good referral is an excellent and appropriate treatment choice for marital and sexual problems that the physician feels unable or unwilling to treat. A referral network offers a potential source of information and training for the physician as well.

Specific counseling skills include techniques for approaching the patient, listening, using appropriate verbal skills, interviewing, evaluating information, and assisting the patient to initiate and take charge of her own solutions. Many of these skills are part of good medical practice.  The addition of specific counseling techniques will support and enhance patient care. 

Approaching the Patient

Primum non nocere means first do no harm. The physician must balance his or her  authoritative status with a manner that is gentle, caring, respectful, empathic, and attending.⁶⁶

Respect is a particular way of viewing another person. It means believing in the worth of a person on the basis of shared humanity without any other qualification. Such respect is not passive but is an active value held by the counselor. The respectful counselor is characterized by a manner that is open, compassionate, gracious, and tough-minded.⁶⁷ Respect communicates powerfully that the counselor believes in the intrinsic worth of the patient, is committed to the patient's well-being, and will persist in supporting and assisting the patient to resolve the situation. In the absence of respect, the use of further counseling techniques will be largely ineffective. Attending is a manner of being present to another person; active listening is what the counselor does while attending. Attending is both physical and emotional.

Physically, the counselor attends by facing the patient, maintaining an open posture, maintaining appropriate eye contact, and remaining relatively relaxed. Respect the patient's space. Sitting either too close or too far away may promote discomfort. Avoiding eye contact may connote embarrassment. Actively seeking eye contact may convey other messages including voyeurism. It can be helpful to position oneself where eye contact can be determined by the patient as desired. Many find that rather than talking across a desk, two similar chairs at right angles facilitate sexual interviewing and counsel. It is less authoritarian and prevents confrontational eye contact.⁶⁸

Psychologic attending includes listening for both the feeling and the content in the verbal and nonverbal messages of the patient. Attending is a difficult skill demanding commitment and concentration on the part of the counselor. The ability to attend improves rapidly with practice.

Techniques for Listening

Active listening requires the avoidance of distraction, awareness of intonation, and attention to feeling as well as content. It is necessary to listen until the patient completes her 'train of thought' before formulating a response. Periodic nods, encouraging sounds, and empathic paraphrases indicate active listening and hearing.

The observation of the patient's facial expressions, movements, and posture can supply important information. One must not make unwarranted assumptions about demeanor, however.

It is helpful, for instance, to ask a woman who is crying what she is feeling before offering her a facial tissue. Because women are socially scripted in our culture not to display anger, tears may be an expression of anger or frustration as often as sadness. (A man, on the other hand, may yell when he is afraid or sad.) Constant dialogue is unnecessary; occasional silence may be comforting and useful for assimilation or processing to occur.

Empathy is twofold. First, it is the ability to look at the world from the perspective or frame of reference of another person and get a feeling for what the other's world is like.⁶⁷ This is quite different from sympathy which is seeing and feeling another's world from one's own perspective.

Second, empathy is the ability to communicate this understanding in a way that shows that feelings have been understood, and the experience underlying the feelings has been also understood.

Empathy is demonstrated by participation in emotional responses. Thus, a look of sadness when the patient is communicating pain or a verbal expression of understanding (e.g. “that must have been very frightening” or “many people would feel sad [hurt, angry] if that happened”) are empathic responses. The experience of accurate empathy may be compared to dancing in step with a partner. Such emotional synchrony is a powerful form of human validation. When empathy is combined with respect, it establishes and maintains rapport and develops trust and openness.

Verbal Skills

There are several simple rules concerning the use of language that apply equally well to marital and sexual inquiry.^{66, 68}

Medical or psychological jargon may confuse rather than clarify. The patient's intelligence, education, and degree of sophistication will help to determine the level of communication. Closed-ended questions, such as  “Have you ever ...” or “Do you ...?” invite a negative response.   Examples of alternatives that convey an accepting nonjudgmental attitude include “When was the last time you ...?” or “How often do you ...?”

Open-ended questions are often more enabling than closed-ended and limited ones. “What sexually transmitted diseases, if any, have you been treated for in the past?” is preferable to “Have you ever been treated for gonorrhea?”

Ubiquitous (universal) statements diminish anxiety, legitimize and normalize concerns, and encourage dialogue. For example, a good technique for the sexual history as part of the review of systems is to begin by a universal or ubiquitous statement followed by an appropriate question. “Most persons experience sexual concerns or problems at times during their lives. What problems, if any, have you experienced?” or “What concerns do you want to share with me?”

Ask one question at a time and allow time for an answer.

Avoid "why" questions that are typically heard as blaming and critical. One can ask a similar question using "how" or "what". “How do you think the problem came to be?” or “What do you think the cause of the problem is?”

Never use a long word when you can use a short one. A complex or latinate word is more likely to be misunderstood. “Do you come?” or "Do you climax?" may be more readily understood than “Do you achieve orgasm?” Usually, neutral colloquial terms are better than vulgar ones. Anatomic charts or models are often helpful during sexual inquiry.

The physician may wish to explain to the patient a personal preference for using medical or scientific terms because they have exact or precise meanings. On the other hand, it is advisable to make clear that there is no expectation or necessity that the patient will use the same terms unless she wishes to. It is essential that myths and misconceptions be tactfully and sensitively corrected at the risk of interruption. If it is not done at the time, you have, in effect, tacitly or implicitly validated the misconception.

Begin with the easy, kind questions and leave the difficult or threatening ones until the end. The patient gains confidence in the physician as questions begin with the less threatening and proceed to the more explicit. Assumptions should be avoided. Do not assume that a patient is familiar with common marital or sexual problems or difficulties. It may be enabling to give examples relevant to the age or life stage, such as power struggles over parenting styles, or vaginal dryness and associated dyspareunia, in the lactating mother or menopausal woman.

Never assume that persons understand the meaning of words. A psychologist ending an AIDS lecture to a senior class was asked by a student what heterosexual meant.⁶⁸ Teenage girls have responded to the question “Are you sexually active?” with “No, I just lie there” or similar statements. 

One must not accept a patient's self-labels such as “He is oversexed” or “I am frigid”. It is important to ask, “What do you mean by that?” or “Can you tell me more about that?”⁶⁹ Many sexual words are either euphemisms—"down there”, “my privates”—or street language.

When investigating exposure to sexually transmitted diseases do not assume that a married woman or her husband is monogamous. In addition, keep in mind that an assumption of heterosexuality or exclusive heterosexuality in a woman, including a married woman, may be fallacious. Sexual interaction and preference are central in the life of the patient, and questions about both are appropriate when taking a marital or sexual history.

Patients frequently wish to know whether their behavior or their partner's requests are normal and seek informed support or reassurance. This is particularly true in the area of sexual concerns. A knowledge base permits you to inform and educate, a primary component of counseling.

Interviewing

The most efficient and effective way to screen for marital and sexual concerns and to offer early intervention in marital conflict is to take a marital and sexual history as part of the routine patient interview and assessment.  Like the medical history, the purpose of a marital and sexual history is to elicit pertinent information in a matter-of-fact, routine manner that is reassuring to the patient and provides enough information for concerns to be addressed.  Marital and sexual histories provide information about the contexts in which the patient lives and about interactions that may evoke or support marital or sexual conflict.

Interviewing skills allow the physician to engage the patient in disclosing marital and sexual concerns, and to help the patient get to the root of the problem or concern quickly and efficiently.

A routine format for obtaining marital and sexual histories provides a way to structure information and pinpoint the marital or sexual interactional pattern. Use of a conversational style and basic counseling skills (attending, active listening, ubiquitous statements) will allay anxiety and elicit information efficiently.

Marital History

During the initial marital history, a brief overview of the life of the marriage from courtship to present should be recorded. The overview itself should be broad but information within each life area may be briefly stated.  Periodically, current information about children, job satisfaction, relationship with in-laws, finances, and social life should be reviewed.

Areas and possible questions to be covered during the marital history taking are:

1. Courtship and marriage patterns (how long; family interaction, sexual involvement, church or other wedding)
2. Number of years married (any separation for work or conflict)
3. Number of children (biologic, step, adopted)
4. Parents or relatives (including other dependents, family interactions)
5. Vocation/work (working inside or outside the home, job satisfaction)
6. Distribution of power (who makes the decisions)
7. Rules (often unspoken) about roles and gender issues (who does what)             
   

The present of conflict can be elicited by ubiquity statements followed by appropriate questions ("Most couple disagree about something now and then.  Is there any disagreement in your marrige that is causing you concern at this time?").

Because marital and sexual concerns are often expressed in vague terms (“we fight a lot” or “we aren't getting along very well”), questions such as “What bothers you the most about that?”, “What part of that is the most upsetting for you?” or “What happens when you fight about that?” assist the patient in articulating the basic conflict issue. The insertion of the words “the most” into a question conveys the sense that such concerns are common and normal. “What bothers you about that?” can be heard as “What bothers YOU about that?”, as though the patient is somehow different from other women.  

Begin with nonthreatening questions (“How long have you been married?”, “How long did you date before you were married?”) and precede to the more specific (“How did your (his) family react to your dating?”, “Were you sexually involved during your courtship?”, “Were either of you sexually involved with someone else while you were dating each other?”).

With practice, marital and sexual histories become an expected and valued part of the medical encounter.  Taking marital and sexual information suggests that the physician is interested and willing to answer, treat, or refer on such issues. If problems are apparent, a more detailed history is obtained.

History taking opens the door to future dialogue if marital and sexual concerns arise. A patient who is a victim of domestic violence may be unable to respond to inquiries about marital or sexual concerns in the initial interview. However, soliciting such information in a routine and caring way may empower her to express concerns during a future visit. Finally, the initial screening history alerts the physician to areas for further evaluation and the need for preventive education.

When To Take a Marital History

A marital history should be taken: (1) as part of the routine health screening interview for a new patient; (2) as part of the annual health screening interviews for existing patients; and (3) when the physician suspects a marital problem or conflict to be present.

Sexual History

A sexual history should be a routine part of the total patient assessment for new patients and may be associated with relevant areas of the medical history, such as the gynecologic history (“Are you sexually active?”, “Do you have any pain or discomfort or other problems during intercourse?”) or the marital history (“Most married couples have sexual concerns from time to time. What concerns, if any, would you like to share with me today?”).^{69, 70}

If the patient is unwilling to share sexual information, the physician should respect the patient's wishes and express willingness to listen to concerns at a later time. History taking can be closed with the question “Is there anything further in the area of sexuality which you would like to bring up now? I hope that as questions do arise over the course of time we will be able to discuss them here”.⁷¹

When a specific sexual problem is identified, a sexual problem history should be done.⁶⁹

The outline for the sexual problem history is:

1. Description of the problem
   
2. Development and course of the problem
   
3. Patient's assessment of the cause of the problem
   
4. History of attempts at resolution of the difficulty
   
5. Patient's expectations and goals

The following information is relevant in sexual problem assessment: a family and personal history, including childhood; adolescence; loss (death, estrangement, divorce); abuse (sexual, physical, emotional, verbal); quality of the family (functional, dysfunctional); sex education and experiences; education; dating and courtship; religion; psychiatric (or psychologic/emotional) history; and the use of alcohol and drugs. Other aspects are early arousal history, masturbation, sexual fantasies, sexual value system, premarital and extramarital experiences, sexually transmitted disease and AIDS prevention, health status, and contraception.

A sexual history is recommended:

1. As part of the new workup (it can be part of the gynecologic history following the menstrual history; part of the social history, part of the personal and marital history, or a separate section)
   
2. When management of organic problems and treatment necessitates inquiry into the patient's sexual practices and sexual value system (e.g. endometriosis, premature labor, premature amniorrhexis, hysterectomy, oophorectomy)
   
3. When the patient presents with explicit sexual problems
   
4. When the patient presents with suspected 'functional' or obscure complaints (hyperventilation, palpitations, chronic pelvic pain, recurrent vaginal discharge without obvious pathogens, chronic concerns that everything is all right “down there” [cancer phobia]).⁶⁶
   

In marital counseling, the marital relationship, rather than the individual partners, is the focus of counseling. Marital assessment is an evaluation of the relationship, its strong and weak points, interactions, satisfactions, and conflicts.

The marital relationship is greater than the sum of its parts (husband and wife), and, as such, has a character and nature of its own. Focus on the marital relationship allays anxiety, and diffuses hostility and defensiveness, allowing the counselor and marital partners to view the relationship as a joint project in which they are all engaged.

The PDC (i.e. present, desired, change) Counseling Model is a three-step, short-term, problem-focused model developed 30 years ago for our personal use in counseling and later used effectively to train professional and nonprofessional counselors.⁷² Based upon the Skilled Helper model of Egan⁶⁷ and influenced by the work of Glasser⁷³ and Satir,⁷⁴ the PDC model includes both cognitive assessment and behavioral management of concerns and problems.

The model offers a simple format that can be used with a variety of concerns and in varied settings. It is designed to be sensitive to time constraints and flexible in the length of time required with the patient. Given a short introduction to a question, an engaged and committed patient may complete the required tasks on her own. In contrast, if the counselor discerns that the patient is unable or unwilling to work on her own, the entire set of steps may be done during brief counseling sessions.

The PDC model includes three assessment steps with questions to be answered in each step. Assessment is designed to lead the patient from vague expressions of concern to a clear and concrete understanding of her concerns. To achieve that goal, emphasis is on “what”. Questions about “why” are avoided. By use of ubiquitous (universal) statements and empathic questions, the patient is encouraged to visualize and describe with as much detail (cognitive and affective) as possible so that a clear picture emerges before moving to the next step of assessment.

The three assessment steps are:

1. P - Present -  (What is happening?)
   
2. D - Desired - (What do you want to have happening?)
   
3. C - Change required - (What is required to get from step 1 [what is?] to step 2 [what is desired?])

Timing within the steps may vary dramatically among patients. A patient may be able to articulate quickly what is happening; be unable to say what she wants; and consequently be unable to make a plan for change. Conversely, a patient may know what she wants; find it very difficult to articulate or evaluate what is happening; and consequently, be unable to formulate changes. A third patient may move quickly through steps 1 and 2 but be unable or unwilling to formulate necessary change.

The first two steps may be reversed while step 3 is always last. The counselor may decide to begin with step 2 and encourage the patient to express hopes, dreams, and wishes before asking how those differ from her present situation.

Step 3 directly confronts the problem. It requires the patient to assume responsibility for the resolution of the problem, and it requires personal action on the part of the patient. Insight is not growth, and resolution requires that something change, even if that is as simple as changing an attitude. Because of its demands on the patient, this is potentially the most frightening step.

The more completely the patient and counselor are able to get to the bottom line and understand the difference between what is happening and what the patient desires or needs to have happening, the more prepared both are to actively address what is required in step 3.

Marital discord and conflict often result from unexpressed, even unrealized, expectations. Frequently, the time spent in clearly articulating what is happening and how that differs from what the wishes and desires of the patient, are all the counseling that is necessary for resolution to be possible.

Regardless of what is required to get the patient to step 3, if the issues is to be resolved, ultimately, the patient must act. It must be recognized that a patient may choose not to act. That choice is an assumption of responsibility for the nonresolution of the problem. Except in those instances where the physician is certain that nonaction will result in life-threatening damage (e.g. in situations involving abuse), the physician should express respect for the patient's wishes and belief in the ultimate ability of the patient to deal with the problem. Such expression should include a gentle assurance that when the patient is ready to act, the physician will be available to offer his or her support.

If the patient chooses to act, the importance of the physician's role in the social support network cannot be overemphasized.  Lasting change requires that action (both thoughts and behaviors) be repeated until it becomes integrated into the life of the patient.  The old adage "practice makes perfect" is a concise prescription for lasting change.  Social support encourages and enables that process.   

Using the PDC Counseling Model

STEP 1. PRESENT - WHAT IS HAPPENING?

Problems and conflicts exist within a context.  "What is happening?" is designed to elicit that context and includes: what, how, when, where, and who.

1. What happens—the behavior and feelings in detail?
   
2. How does it happen—how the behavior or feelings are manifested or not manifested (e.g. do participants shout, cry, hit, withdraw, leave the area?)
3. When does it happen—on the weekend, following a visit to in-laws, when the person is drinking?
   
4. Where does it happen—exact location or place (e.g. at home in the bedroom or kitchen, in the car, at mother's?)
5. Who is present when conflict occurs—the couple only, a child, other person?
   

STEP 2.  DESIRED (Dreams) -  WHAT DOES THE PATIENT WANT TO HAVE HAPPEN?

One useful way to approach this question is with a simple 'magic wand' exercise.

“If you could wave a magic wand and make everything just like you want it to be, how would it be?”

Additional helpful questions may be:

“What would you be doing (feeling, saying) if everything were just like you wanted it to be?”

“What would he be doing (saying, feeling) ...?”

“Where would you be? (i.e. what would the setting look like) ...?”

“Who would be there?”

The goal of step 2 is to draw the clearest, most detailed picture of what the patient wants or needs, and this goal must be kept firmly in mind. Both cognitive and affective wants and needs should be expressed, and either may be primary for description. “What would you feel like if everything were just like you wanted it to be?” may be an easier question to answer than “What would you be doing?”

STEP 3. CHANGE -  HOW DOES THE PATIENT GET FROM STEP 1 TO STEP 2?

Getting from 'what is' to 'what is desired' may be as simple as making a list of things to be done or as complex as working out a detailed therapeutic plan involving a series of counseling sessions, a suggested reading list, assigned exercises, and conjoint couple therapy. The result of step 3 should be a practical plan that sets forth, in as clear a manner as possible, what must be done and who will do it.  The counselor may think of adding 'choices' and 'courage to act' to the C for change.  

Information about the diagnosis and treatment of sexual dysfunction is available to the obstetrician-gynecologist.⁷⁵ Masters and Johnson³⁶ emphasized that most sexual problems are not the result of deep-seated psychosexual conflicts, but are derived from sexual ignorance and sociocultural deprivation. Further, the interpersonal relationship is the appropriate therapeutic focus rather than the identified patient. Short-term conjoint treatment with the addition of assigned home tasks, as opposed to a long-term psychoanalytic or dynamic approach, can be highly successful in resolving sexual problems.⁷⁶

The goal of treatment in general is that of the (direct) removal of symptoms rather than the (dynamic) attainment of insight. Behavioral modification is founded on learning theory, where dysfunctions are seen as consequences of disturbed learning, conditioning, or habit. The behavioral approach emphasizes skill training in effective sexual behavior, reducing anxiety about performance, and increasing communication between partners.⁷⁷

The PLISSIT Model is a conceptual scheme for the rapid treatment of sexual concerns.⁶⁹ P-L-I-S-S-I-T stands for four increasingly deep levels of therapeutic intervention: (1) permission, (2) limited information, (3) specific suggestions, and (4) intensive therapy. It is a concept that can be used by therapist and nontherapist alike. The first three levels are considered brief therapy (or counseling) and are applicable for the majority of sexual concerns. The PLISSIT approach can be used in a variety of settings and is suitable when there is little time available. The model can be tailored to the degree of competence (knowledge, comfort, counseling skills) of the physician, because each level requires increasing amounts of training or experience.

Permission

Permission is described as giving permission to the patient to experience certain attitudes, feelings, or behaviors including reassurance of normalcy. Permission giving does not require a great deal of preparation on the part of the physician.

Permission may be used, when appropriate, to normalize covert behaviors, such as thoughts, fantasies, dreams, and feelings and to dispel anxiety of guilt. For example, a man may experience an erection while playing with his son on his lap, and lactating mothers have been known to wean their infants early because of psychologic discomfort experienced after becoming aroused during breastfeeding.⁴³ Reassuring patients that such arousal is normal and the result of tactile stimulation rather than sexual thoughts or fantasies can be very helpful in assuaging guilt.

A word of caution about permission: while it is ultimately up to the individual client to choose whatever behavior that he or she wishes to engage in, 'blanket' permission giving by the physician may not be appropriate if the client is not making an informed choice. Learning theory suggests, and clinical evidence substantiates, that systematically associating thoughts and fantasies with sexual activity is a powerful means for conditioning arousal to almost any stimulus.⁷⁸

Limited Information

Limited information provides the patient with specific factual information directly relevant to her concern. Concerns about breast and genital size or shape, the normality of coital positions other than the missionary position, and orogenital sex are typical concerns. Additional sexual concerns include ideal or normal coital frequency, sexual relations during pregnancy, and masturbation. Patients often want to know whether certain behavior is wrong or bad or dangerous. Appropriate, informative reassurance can be remarkably helpful.

Two options are available to the primary physician when limited information is ineffectual in resolving patient concerns. First, he or she can refer the patient to a sex therapist or a psychologist with expertise in psychosexual problems. Alternatively, he can progress, if confident, to the next level of sexual counseling.

Specific Suggestions

In contrast to the first two levels of the PLISSIT Model, which do not generally demand behavioral modification, specific suggestions are direct attempts to facilitate behavioral change by the patient to reach her goals. The specific suggestion level, according to Annon, necessitates administering a sexual problem history. It is essential that premature, inappropriate suggestions not be given on hearing a patient's presenting labels. The specific, unique circumstances must be heard and unwoven first. Specific suggestions might include coital proscription, sensate focus,³⁶ sexual self-awareness tasks,^{79, 80} or the admonition to the male partner, “Don't use your penis sexually if you are anxious or not aroused.”⁸¹

This level of treatment lends itself well to physiologic dysfunctions including problems with arousal,³⁷ orgasm,³⁷ vaginismus,⁸² and dyspareunia.⁸³ Treatment is generally most effective when the patient is seen with her husband and mutual understanding, communication, and cooperation is maximized.

Intensive Therapy

Intensive therapy is indicated when brief therapy (or sexual counseling) incorporating the first three levels of the PLISSIT model is unsuccessful after a few sessions. For most gynecologists without formal training, referral to a bonafide sex therapist or a psychologist with special skills in this area is indicated. There are times in the course of sexual counseling when it becomes obvious that significant psychopathology exists or that marital disharmony is extreme or primary. Decompensated psychotics may present with sexual problems. These patients should be referred to a psychiatrist.

Finally, we share the opinion “... that it may be unethical to involve a client in an expensive, long-term treatment program without first trying to resolve his or her problem from within a brief therapy approach.”⁷⁸

Closing a Patient Appointment

Most experienced obstetrician-gynecologists have experienced the patient who, during the final moments, or even when standing up to leave, suddenly volunteers deeply painful, relevant, or pertinent information. What the physician may perceive as inappropriate timing reflects the patient's ambivalence and concern about raising an anxiety-laden issue.

One of our most dramatic counseling examples was a young woman who paused at the open door with her hand on the doorknob after her session had ended. Suddenly she turned back and said, “I was raped by the first boy I ever dated”, thus opening a painful and potentially complex counseling issue. Acknowledging the pain of this issue, an invitation was given for her to return to discuss the issue so that we could take as much time as she wanted. A follow-up appointment was immediately scheduled.

An empathic response followed by a kind and gentle invitation to return, and the scheduling of an appointment may be more effective than attempting to address the issue at the moment. This approach validates the patient's concern, conveys the physician's belief in her ability to resolve the concern, and leaves an opening for a therapeutic examination of the concern.⁷⁸

Transference and Countertransference

Transference is common in the counseling setting. Briefly defined, transference occurs when the feelings, positive or negative, that the client feels toward others in her or his life are transferred to the counselor.^{59, 72}Countertransference occurs when feelings, positive or negative, that the counselor feels to others in his or her life are transferred to the patient.

Feelings can range from unreasoning dislikes, negative responses to authority, sexual feelings and needs, instant attractions or antipathies, to vague, uneasy, unidentifiable concerns. Sudden, intense feelings on the part of physician or patient should be examined by the physician as possibly transferred or countertransferred.

Respect for oneself and the patient will allow time to assess feelings without panic, misinterpretations, or a rush to bend or change the patient's or one's own feelings. Counselors who do not deal with their own issues and feelings are particularly vulnerable to these difficulties.

Transference and countertransference must be dealt with routinely in the life of every physician or counselor. It helps if the physician keeps his or her ego out of the session. Counseling is designed to provide the patient with an atmosphere conducive to growth and self-responsibility. It is irresponsible for a counselor to attempt to solve the patient's problems. Rather, the effective counselor provides a mirror into which the patient can see, as clearly as possible, the issues for herself and be enabled to confront and resolve them. Lasting change must come from within.

Doctor/Patient Sex

A Canadian position paper on sexual exploitation of patients by physicians states that “The physician must avoid initiating or responding to any form of sexual advances. To sexualize the relationship is a clear breach of trust.”⁸⁴ This is, after all, merely a restatement of the Hippocratic Oath from the fourth century, BC:

“Into whatever houses I enter I will go into them for the benefit of the sick and will abstain from every voluntary act of mischief and corruption and further from the seduction of females or males, or freemen and slaves.”⁸⁵

Sexual or romantic interaction exploits a patient's vulnerability and violates her trust. “It jeopardizes the well-being of patients and carries an immense potential for harm.”⁸⁶

Helping is always "for better or for worse".⁶⁷ To assist others, we must ourselves be involved; we cannot be involved and remain neutral. Marital counseling is a pragmatic extension of the healing arts of the physician 'for better'.