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A case of chronic back pain and the “unilateral” treatment of marital problems
J. Brhar.
llcr.
& Exp
Psyckiut.
Vol.
7, pp. 47-50.
Pergamon
Press,
1976.
Printed
is Orcat
Britain.
A CASE OF CHRONIC BACK PAIN AND THE *‘UNILATERAL” TREATMENT OF MARlTAL PROBLEMS EDWIN G. SCHEIDERER* College of Medicine and Dentistry of New Jersey and DOUGLASA. BERNSTEIN Western Washington
State College
Summary-When a client’s problems are deeply rooted in his or her marriage, a therapist should usually work with both husband and wife. However, when either spouse refuses cooperation, unilateral marriage counseling. in which the client identifies problem areas in the marriage and becomes a behavioral engineer (with the therapist as a consultant), can be employed. This orocedure is illustrated in the case of a 52-yr-old woman who reported numerous marital problems accompanied by chronic back pain.
was 15, becoming progressively worse from midday until bedtime. Repeated medical investigation had failed to provide a physiological basis for the pain. Neither a series a eight electroshock treatments nor a brief participation in a sensitivity-type group experience had alleviated it. Although Mrs. X was able to maintain her job as a secretary, the pain hampered her freedom of movement on the job; and also her ability to fall asleep. Mrs. X’s marriage was unsatisfactory. Her husband spent all of his time either at work or engaged in his hobbies. Conversation was minimal and meals were often eaten separately. She had a close relationship with both of her college-age daughters, and several friends; yet she found it difficult to view herself as a competent, worthwhile person. She was perfectionistic and constantly afraid of criticism from those around her.
of action in most marital problems is to have both husband and wife involved in the treatment program. Unfortunately, this cannot always be accomplished since spouses often not only refuse to admit to any problem but decline even to visit a therapist. In such cases, therapeutic goals may still be decided upon and treatment programs set up in which the husband or wife becomes a behavioral engineer for the marriage (That-p and and Wetzel, 1969). This means that the husband or wife who initially sought professional help acts both as client and mediator between therapist and spouse. Assuming that a client has described his or her marriage in reasonably accurate terms, and that the desired marital changes are appropriate, realistic, and ethically permissible, unilateral marriage counseling can be a viable treatment approach. THE fDrz~f_ course
CASE HISTORY TREATMENT
Mrs. X was a S2-yr-old woman who came to a psychological clinic complaining of a chronic, low back pain that had occurred daily since she
It appeared that Mrs. X’s pain was related to tension due to her negative self-evaluation in
*Requests for reprints should be sent to Edwin G. Scheiderer, College of Medicine and Dentistry Rutgers Mental Health Center, P.O. Box 101, Piscataway, N.J. 08854. 47
of New Jersey,
48
EDWIN G. SCHEIDERER and DOUGLAS A. RERNSTETN
the marriage and in social interactions and that changes in both areas would be necessary to insure positive changes in her back condition. Mr. X refused repeated invitations to visit the clinic for discussion of the marital situation, and so, since Mrs. X was an intelligent woman, it was hypothesized that she could learn to implement agreed-upon programs unilaterally. A set of overlapping programs was developed in this way and is described in relation to specified treatment targets. Back pain
Mrs. X was trained in progressive relaxation (Bernstein and Borkovec, 1973 ; Jacobson, 1938; Wolpe, 1958). Emphasis was given to the muscles of the lower back, which was tensed by arching the back.
and listen to my opinions and feelings”. Mrs. X was asked to subvocally repeat any of the statements which would be appropriate while engaged in a specific verbal interaction. As a third step, Mrs. X was asked to make a list of positive things she could do for and say to other people as well as herself. In addition, she was to record examples of others’ positive actions and comments toward her. The list included compliments, “favors”, and the like. In this manner, Mrs. X was maximizing her opportunities positively to reinforce her own “self-evaluative/assertion” statements. Weight reduction program
Related to her low self-opinion was Mrs. x’s overweight. The weight reduction plan of Stuart and Davis (1972) was introduced with minor changes.
Self-evaluation
A major area of concern was Mr. X’s indifference to Mrs. X which was related, in part, to her own low self-evaluation. It was emphasized that by utilizing cognitive restructuring procedures, Mrs. X could gain self-control over her own evaluative thoughts (cf. Cautela, 1969; Kanfer and Phillips, 1970; Ellis, 1962; Goldfried, Decenteceo and Weinberg, 1974). The first step was to have Mrs. X keep an anecdotal record of all interpersonal interactions lasting more than 5 minutes. She was briefly to summarize the antecedents, her overt verbal behavior and covert thoughts, and finally the consequences. During ongoing verbal interactions, it became apparent that her thoughts and overt verbal responses were heavily intertwined. This procedure made Mrs. X more aware of how she was allowing her own internal evaluative thoughts to supercede the actual feedback she was getting from other people. The second step consisted of Mrs. X composing a list of ten positive “self-evaluative/ assertion” statements which she could periodically read over and subvocalize until they began to occur more spontaneously. These statements included, “I’m just as important a person as my husband” and “most people will respect me
Communication and interaction with husband It was suggested that Mrs. X spend more time
talking to her husband, even if this meant turning off the television set or following him around the house. Conversations began around topics of mutual interest, such as the day’s activities, reactions to current events, or information related by a friend, and provided a context in which serious discussions of topics relating to marital complaints could later be brought up. It was pointed out that Mrs. X’s previous habit of waiting for the proper time to discuss things usually resulted in such topics never being discussed. Mrs. X consulted with the therapist in defining problem areas of the marriage and was advised on how to deal with such problems--e.g. she was given an explanation of the principles of reinforcement. and extinction, and shown how to apply them to specific problems. One goal was to have her husband speak in a more positive and complementary way both about things she had done exceptionally well and also about jobs done routinely (cooking, house cleaning, errands, and the like). She was also made aware of the need to model behavior she desired from her husband, and to reinforce his appropriate
BACK
PAIN AND THE “UNILATERAL”
responses. If he was unjustitiably critical, she was to ignore his criticism and tell herself that she hadn’t done anything to justify it. In addition, she was to try to change the negative tone of the conversation in any way possible, even if it meant changing the topic. Wherever her husband’s behavior needed to be modified, Mrs. X was carefully to apply or withhold reinforcement. Reinforcers consisted of positive comments and/or non-verbal responses. Mrs. X constructed a “menu” of reinforcers for her husband (offering him a sandwich or a dish of ice cream, running an errand for him, buying him a record or a necktie) and, in each case, she was to informally verbalize the specific contingency, e.g. “1 just wanted to make a pot of coffee for you to show you that I really appreciated your starting the car for me this morning”. Along with her relative inexperience in freely disclosing positive thoughts and feelings to her husband, Mrs. X also found it difficult to make routine requests. She was therefore instructed to define 12 assertive responses she wanted to be able to make and to rank them in self-defined order of difficulty. A new response was assigned each week following successful completion of the preceding response. These responses ranged from asking Mr. X to stop off at a store on the way home to informing him that she would go on vacation with him only if he agreed to visit her out-of-town relatives. Additional responses were later elicited in regard to Mrs. X’s work situation and inability to be assertive with her boss. Social activity
Mrs. X expressed a great desire to get out and engage in more social activity, especially with her husband. Her previous attempts to initiate such activity had usually resulted in failure and sequential feelings of rejection, anger, guilt, and intensified back pain. She had almost given up social activities, except for visits to a few close friends. This self-imposed social deprivation not only reduced her pleasure in life but also reinforced her attitude that she
TREATMENT
OF MARITAL
PROBLEMS
49
was unworthy and undeserving. She was asked to list 20 preferred activities (e.g. shopping, movies, going out to dinner) and each week to select at least one activity to enjoy alone or with a friend and at least one activity in which she would ask her husband to participate. She was free to add new activities to the list and substitutions were allowed for previously agreed upon activities. The goals here were to allow her husband continued opportunities for spending more time with Mrs. X and to help her learn that she could go out without him. He was free to refuse an invitation, but these occasions provided Mrs. X with experience in accepting a refusal without self-criticism and in selecting an alternative activity. RESPONSE TO TREATMENT Mrs. X was seen for a total of 20 sessions over a period of 7 months. The frequency and intensity of the back pain gradually decreased until she had no pain whatever during the last one and one-half months of therapy. Written contact 6 months after termination revealed no further back problems. There were major changes in the marital situation. Mr and Mrs. X spent every evening meal together as well as a period of at least 30 min discussing the day’s events, problem solving, or listening to music. Once a week, they went to a social function, e.g. a dog show, the movies, a restaurant, or an office party. Mrs. X described the changes as a return to ‘Ccourting days” and the changes were best illustrated by their decision to resume sexual intercourse (usually once a week) after several years’ abstinence. Her weight had decreased from 220 lb to 175 lb. Mrs. X also became more at ease in social activities whether alone or with a friend. She joined a history club and the U.S.O., and was able to develop two new close friendships. She reported feeling more comfortable with other people in public and could state her opinion without fear of criticism. She engaged in one social activity per week alone, with a friend, or in conjunction with a social organization.
50
EDWIN
0. SCHEIDERER
and DOUGLAS
As a result of her experience as a behavioral engineer, Mrs. X was much more aware of how other people’s behavior interacted in a complex way with her own. Thus she no longer labelled herself the sole cause of her problems. It was suggested that because she had learned many specific skills which could be helpful to other people, she might consider joining some type of volunteer organization (e.g. a “hotline” for distressed people or “mental hospital companion”) and thus utilize her listening skills. She was aware of her limitations as a “therapist”, but felt very self-confident in her interactions with other people, and proud that the therapist had made this suggestion. DISCUSSION Unilateral marriage counseling is an aspect of individual therapy, in which the client is not seen as the main focus of attention, but the interaction between husband and wife. The client soon realizes he is changing a system and not just his own attitudes or feelings. There are four major assignments for the client-mediator. First, he must have a reasonably accurate assessment of the problem areas, including a conception of what behaviors are not desirable and can be changed. The second task is to formulate, with the therapist, a treatment program for the client and the spouse. It is, of course, important that the therapist and client weigh the probable consequences of each
A. BERNSTEIN
change. Next, the client must implement the suggested treatment program. At this point, the client assumes a great deal of responsibility since the therapist is not present during the interactions between client and spouse. The client must realize that change is two-sided and avoid the temptation to justify any action as being sanctioned by the therapist. The final stage is reassessment. The client reports to the therapist what changes have occurred. Such changes may be in the area of verbal interaction, work routines, leisure activities, sexual behavior and related behavior. REFERENCES
BERNSTEIN D. A. and BORKOVECT. D. (1973) Progressive Relaxation Training: A Manual fbr Therapists. Research Press, Champaign, Illinois.. CAUTELAJ. R. (1969) Behavior therauv and self-control : Techniques &d implications, Behavior Therapy: Appraisal and Status (Edited by FRANKS C. hf.). McGraw-Hill, New York. ELLIS A. (1962) Reason and Emotion in Psychotherapy, Lyle Stuart, New York. GOLDFR~EDM. R.. DECENTECEO E. T. and WEINBERGL. (1974) Systematic rational restructuring as a self-control iechnique, Behav. Therapy 5,247-254, JACOBSON E. (1938) Progressive Relaxation, University of Chicago Press, Chicago. KANFERF. H. and PHILLIPSU. S. (1970) Learning Foundations of Behavior Theraov. Wiley. New York. STUARTk. B. and D*vrs‘B: (197ijSiim Chance in a Fat World: Behavioral Control of Obesity, Research Press, Champaign, Ill. THARP R. and WETZEL R. (1969) Behavior Modification in the Natural Environment, Academic Press, New York. WOLPE J. (1958) Psychotherapy by Reciprocal Inhibition, Stanford University Press. Stanford California.
llcr.
& Exp
Psyckiut.
Vol.
7, pp. 47-50.
Pergamon
Press,
1976.
Printed
is Orcat
Britain.
A CASE OF CHRONIC BACK PAIN AND THE *‘UNILATERAL” TREATMENT OF MARlTAL PROBLEMS EDWIN G. SCHEIDERER* College of Medicine and Dentistry of New Jersey and DOUGLASA. BERNSTEIN Western Washington
State College
Summary-When a client’s problems are deeply rooted in his or her marriage, a therapist should usually work with both husband and wife. However, when either spouse refuses cooperation, unilateral marriage counseling. in which the client identifies problem areas in the marriage and becomes a behavioral engineer (with the therapist as a consultant), can be employed. This orocedure is illustrated in the case of a 52-yr-old woman who reported numerous marital problems accompanied by chronic back pain.
was 15, becoming progressively worse from midday until bedtime. Repeated medical investigation had failed to provide a physiological basis for the pain. Neither a series a eight electroshock treatments nor a brief participation in a sensitivity-type group experience had alleviated it. Although Mrs. X was able to maintain her job as a secretary, the pain hampered her freedom of movement on the job; and also her ability to fall asleep. Mrs. X’s marriage was unsatisfactory. Her husband spent all of his time either at work or engaged in his hobbies. Conversation was minimal and meals were often eaten separately. She had a close relationship with both of her college-age daughters, and several friends; yet she found it difficult to view herself as a competent, worthwhile person. She was perfectionistic and constantly afraid of criticism from those around her.
of action in most marital problems is to have both husband and wife involved in the treatment program. Unfortunately, this cannot always be accomplished since spouses often not only refuse to admit to any problem but decline even to visit a therapist. In such cases, therapeutic goals may still be decided upon and treatment programs set up in which the husband or wife becomes a behavioral engineer for the marriage (That-p and and Wetzel, 1969). This means that the husband or wife who initially sought professional help acts both as client and mediator between therapist and spouse. Assuming that a client has described his or her marriage in reasonably accurate terms, and that the desired marital changes are appropriate, realistic, and ethically permissible, unilateral marriage counseling can be a viable treatment approach. THE fDrz~f_ course
CASE HISTORY TREATMENT
Mrs. X was a S2-yr-old woman who came to a psychological clinic complaining of a chronic, low back pain that had occurred daily since she
It appeared that Mrs. X’s pain was related to tension due to her negative self-evaluation in
*Requests for reprints should be sent to Edwin G. Scheiderer, College of Medicine and Dentistry Rutgers Mental Health Center, P.O. Box 101, Piscataway, N.J. 08854. 47
of New Jersey,
48
EDWIN G. SCHEIDERER and DOUGLAS A. RERNSTETN
the marriage and in social interactions and that changes in both areas would be necessary to insure positive changes in her back condition. Mr. X refused repeated invitations to visit the clinic for discussion of the marital situation, and so, since Mrs. X was an intelligent woman, it was hypothesized that she could learn to implement agreed-upon programs unilaterally. A set of overlapping programs was developed in this way and is described in relation to specified treatment targets. Back pain
Mrs. X was trained in progressive relaxation (Bernstein and Borkovec, 1973 ; Jacobson, 1938; Wolpe, 1958). Emphasis was given to the muscles of the lower back, which was tensed by arching the back.
and listen to my opinions and feelings”. Mrs. X was asked to subvocally repeat any of the statements which would be appropriate while engaged in a specific verbal interaction. As a third step, Mrs. X was asked to make a list of positive things she could do for and say to other people as well as herself. In addition, she was to record examples of others’ positive actions and comments toward her. The list included compliments, “favors”, and the like. In this manner, Mrs. X was maximizing her opportunities positively to reinforce her own “self-evaluative/assertion” statements. Weight reduction program
Related to her low self-opinion was Mrs. x’s overweight. The weight reduction plan of Stuart and Davis (1972) was introduced with minor changes.
Self-evaluation
A major area of concern was Mr. X’s indifference to Mrs. X which was related, in part, to her own low self-evaluation. It was emphasized that by utilizing cognitive restructuring procedures, Mrs. X could gain self-control over her own evaluative thoughts (cf. Cautela, 1969; Kanfer and Phillips, 1970; Ellis, 1962; Goldfried, Decenteceo and Weinberg, 1974). The first step was to have Mrs. X keep an anecdotal record of all interpersonal interactions lasting more than 5 minutes. She was briefly to summarize the antecedents, her overt verbal behavior and covert thoughts, and finally the consequences. During ongoing verbal interactions, it became apparent that her thoughts and overt verbal responses were heavily intertwined. This procedure made Mrs. X more aware of how she was allowing her own internal evaluative thoughts to supercede the actual feedback she was getting from other people. The second step consisted of Mrs. X composing a list of ten positive “self-evaluative/ assertion” statements which she could periodically read over and subvocalize until they began to occur more spontaneously. These statements included, “I’m just as important a person as my husband” and “most people will respect me
Communication and interaction with husband It was suggested that Mrs. X spend more time
talking to her husband, even if this meant turning off the television set or following him around the house. Conversations began around topics of mutual interest, such as the day’s activities, reactions to current events, or information related by a friend, and provided a context in which serious discussions of topics relating to marital complaints could later be brought up. It was pointed out that Mrs. X’s previous habit of waiting for the proper time to discuss things usually resulted in such topics never being discussed. Mrs. X consulted with the therapist in defining problem areas of the marriage and was advised on how to deal with such problems--e.g. she was given an explanation of the principles of reinforcement. and extinction, and shown how to apply them to specific problems. One goal was to have her husband speak in a more positive and complementary way both about things she had done exceptionally well and also about jobs done routinely (cooking, house cleaning, errands, and the like). She was also made aware of the need to model behavior she desired from her husband, and to reinforce his appropriate
BACK
PAIN AND THE “UNILATERAL”
responses. If he was unjustitiably critical, she was to ignore his criticism and tell herself that she hadn’t done anything to justify it. In addition, she was to try to change the negative tone of the conversation in any way possible, even if it meant changing the topic. Wherever her husband’s behavior needed to be modified, Mrs. X was carefully to apply or withhold reinforcement. Reinforcers consisted of positive comments and/or non-verbal responses. Mrs. X constructed a “menu” of reinforcers for her husband (offering him a sandwich or a dish of ice cream, running an errand for him, buying him a record or a necktie) and, in each case, she was to informally verbalize the specific contingency, e.g. “1 just wanted to make a pot of coffee for you to show you that I really appreciated your starting the car for me this morning”. Along with her relative inexperience in freely disclosing positive thoughts and feelings to her husband, Mrs. X also found it difficult to make routine requests. She was therefore instructed to define 12 assertive responses she wanted to be able to make and to rank them in self-defined order of difficulty. A new response was assigned each week following successful completion of the preceding response. These responses ranged from asking Mr. X to stop off at a store on the way home to informing him that she would go on vacation with him only if he agreed to visit her out-of-town relatives. Additional responses were later elicited in regard to Mrs. X’s work situation and inability to be assertive with her boss. Social activity
Mrs. X expressed a great desire to get out and engage in more social activity, especially with her husband. Her previous attempts to initiate such activity had usually resulted in failure and sequential feelings of rejection, anger, guilt, and intensified back pain. She had almost given up social activities, except for visits to a few close friends. This self-imposed social deprivation not only reduced her pleasure in life but also reinforced her attitude that she
TREATMENT
OF MARITAL
PROBLEMS
49
was unworthy and undeserving. She was asked to list 20 preferred activities (e.g. shopping, movies, going out to dinner) and each week to select at least one activity to enjoy alone or with a friend and at least one activity in which she would ask her husband to participate. She was free to add new activities to the list and substitutions were allowed for previously agreed upon activities. The goals here were to allow her husband continued opportunities for spending more time with Mrs. X and to help her learn that she could go out without him. He was free to refuse an invitation, but these occasions provided Mrs. X with experience in accepting a refusal without self-criticism and in selecting an alternative activity. RESPONSE TO TREATMENT Mrs. X was seen for a total of 20 sessions over a period of 7 months. The frequency and intensity of the back pain gradually decreased until she had no pain whatever during the last one and one-half months of therapy. Written contact 6 months after termination revealed no further back problems. There were major changes in the marital situation. Mr and Mrs. X spent every evening meal together as well as a period of at least 30 min discussing the day’s events, problem solving, or listening to music. Once a week, they went to a social function, e.g. a dog show, the movies, a restaurant, or an office party. Mrs. X described the changes as a return to ‘Ccourting days” and the changes were best illustrated by their decision to resume sexual intercourse (usually once a week) after several years’ abstinence. Her weight had decreased from 220 lb to 175 lb. Mrs. X also became more at ease in social activities whether alone or with a friend. She joined a history club and the U.S.O., and was able to develop two new close friendships. She reported feeling more comfortable with other people in public and could state her opinion without fear of criticism. She engaged in one social activity per week alone, with a friend, or in conjunction with a social organization.
50
EDWIN
0. SCHEIDERER
and DOUGLAS
As a result of her experience as a behavioral engineer, Mrs. X was much more aware of how other people’s behavior interacted in a complex way with her own. Thus she no longer labelled herself the sole cause of her problems. It was suggested that because she had learned many specific skills which could be helpful to other people, she might consider joining some type of volunteer organization (e.g. a “hotline” for distressed people or “mental hospital companion”) and thus utilize her listening skills. She was aware of her limitations as a “therapist”, but felt very self-confident in her interactions with other people, and proud that the therapist had made this suggestion. DISCUSSION Unilateral marriage counseling is an aspect of individual therapy, in which the client is not seen as the main focus of attention, but the interaction between husband and wife. The client soon realizes he is changing a system and not just his own attitudes or feelings. There are four major assignments for the client-mediator. First, he must have a reasonably accurate assessment of the problem areas, including a conception of what behaviors are not desirable and can be changed. The second task is to formulate, with the therapist, a treatment program for the client and the spouse. It is, of course, important that the therapist and client weigh the probable consequences of each
A. BERNSTEIN
change. Next, the client must implement the suggested treatment program. At this point, the client assumes a great deal of responsibility since the therapist is not present during the interactions between client and spouse. The client must realize that change is two-sided and avoid the temptation to justify any action as being sanctioned by the therapist. The final stage is reassessment. The client reports to the therapist what changes have occurred. Such changes may be in the area of verbal interaction, work routines, leisure activities, sexual behavior and related behavior. REFERENCES
BERNSTEIN D. A. and BORKOVECT. D. (1973) Progressive Relaxation Training: A Manual fbr Therapists. Research Press, Champaign, Illinois.. CAUTELAJ. R. (1969) Behavior therauv and self-control : Techniques &d implications, Behavior Therapy: Appraisal and Status (Edited by FRANKS C. hf.). McGraw-Hill, New York. ELLIS A. (1962) Reason and Emotion in Psychotherapy, Lyle Stuart, New York. GOLDFR~EDM. R.. DECENTECEO E. T. and WEINBERGL. (1974) Systematic rational restructuring as a self-control iechnique, Behav. Therapy 5,247-254, JACOBSON E. (1938) Progressive Relaxation, University of Chicago Press, Chicago. KANFERF. H. and PHILLIPSU. S. (1970) Learning Foundations of Behavior Theraov. Wiley. New York. STUARTk. B. and D*vrs‘B: (197ijSiim Chance in a Fat World: Behavioral Control of Obesity, Research Press, Champaign, Ill. THARP R. and WETZEL R. (1969) Behavior Modification in the Natural Environment, Academic Press, New York. WOLPE J. (1958) Psychotherapy by Reciprocal Inhibition, Stanford University Press. Stanford California.