A few years ago I found the blog,
Lives of Doctor's Wives where many stages and phases of medical spouses gather to give each other advice and ask the age old questions like, 'what do you do when your nine month old cries whenever her dad enters the room because she thinks he's a stranger?' We have really had this happen with Naomi, but don't worry, she grew out of it when Chris got to be around more. But whether it's a medical marriage, military marriage (which in my opinion get the award for taking on hard things and making them work), the new, student, unemployed, under-great-stress or I-think-we-have-too-many-kids, and even the we-can't-have-kids marriage there are always points in life when a couple needs to reevaluate what in the world they're doing to each other. In our house I can do any number of things that, from a psychological standpoint, might help me feel like Chris and I are working on our relationship. But I should have got it in my head sooner that he, like many doctors, and almost all guys, need a streamlined and clinical answer to common cold comments like, 'we don't spend enough time together' or 'why can't we ever really talk?' The article pasted below is one that was shared by Kathy the Wingspouse, contributor to the Lives of Doctor's Wives blog and captain of her own company called
Wingspouse. My cold-hearted surgeon husband skimmed it for content the first time I duct-taped him in the chair and threatened that he wouldn't get any meals besides hospital food until he read it. But after he skimmed it for content, he slowed down, read it thoroughly and after gnawing his way through the duct tape came into the next room and said simply, "I wish we'd known that sooner." photo by Megan Wilcken of
Nutmeg PhotographyThe whole thing is below but the nitty gritty of it all is in this excerpt...
"Often we define the dimensions of interpersonal relationships in terms of boundaries, power and intimacy. Of these, intimacy is held to be paramount. Alexander (15) offers this definition: "Intimate contact is that close contact between two individuals in which they reveal themselves in all their weakness without fear. It is a relationship in which barriers which normally surround the self are down. It is a relationship which characterizes the best marriages and all true friendship. We often call it love."
If a relationship between two human beings is to mature into intimacy, it must meet at least two conditions: (1) the people concerned must see each other often - almost every day, although not necessarily for long at each time; and (2) they must see each other under informal conditions, without the special overlay of role that we usually wear in public. Given these conditions, they likely will share the ultimate meaning of their lives as well.
An impressive body of work emphasizes the importance of the quality and quantity of interpersonal intimacy to marital adjustment, family functioning and psychosocial adaptation. Waring (7) identifies eight facets of intimacy:
• Conflict resolution - the ease with which differences of opinion are resolved;
• Affection - the degree to which feelings of emotional closeness are expressed by the couple;
• Cohesion - a feeling of commitment to the marriage;
• Sexuality - the degree to which sexual needs are communicated and fulfilled by the marriage;
• Identity - the couple's level of self-confidence and self-esteem;
• Compatibility - the degree to which the couple is able to work and play together comfortably;
• Expressiveness - the degree to which thoughts, beliefs, attitudes and feelings are shared within the marriage and as well, the couple's level of self-disclosure; and
• Autonomy - the success with which the couple gains independence from their families of origin and their offspring."
THE PHYSICIAN'S MARRIAGE
The Struggle for Intimacy
________________________________________
MERVILLE 0. VINCENT, MD, CM, MRC PSYCH, FRCP (c)
GEORGE R. SLATER, STM, PH D
The doctor's marriage is often one of the casualties of that high-stress profession. In the search for marital intimacy, physician and spouse face a profession that has the intrinsic problems of high role expectation, autonomy in setting work limits, and the urgency of life-critical outcomes, as well as the conflict between medical and marital roles. The latter is more than a competition for quality time and attention: the skills and personality traits involved in the curing role contrast sharply with those required in the caring role of marriage. The physician's personality, honed to a medical model of clinical objectivity and technical excellence, may actually inhibit the emotional warmth and personal disclosure needed for intimacy. Complicating the situation is evidence that some physicians have an inordinate need to serve others and to sacrifice themselves until personal problems become chronic. A further stressor of the medical marriage is the lowering of social esteem for the profession itself. Finally, suggestions are made that will help physicians to value themselves and their personal relationships. This should result in a better tolerance of stress, less stress, and should produce better patient care.
It seems as if, in addition to the Hippocratic Oath, physicians have adopted a stoic motto that says, "Doctors are supposed to care for others ... we're not supposed to need care ourselves" (1). However, physicians are mortal and they often work under great stress and increasingly are seen to be a profession at risk of breakdown.
An extensive literature (2-5) demonstrates that physicians have an incidence of depression and suicide, drug dependency and marital breakdown that is significantly higher than the general population. A Scottish study (4) found that physicians had twice the rate of admission to psychiatric facilities as other men of the same social class. Among physicians' wives seeking psychiatric care (3), depression was the most common presentation and "the chief precipitating factor in the spouse's illness was absence of the husband - the feeling of being excluded or left out."
In these studies, an important indicator of general mental health was the quality of the marital relationship, and this finding offers an insight into the importance of the physician's personal needs. As Glen and Weaver (6), have noted, marital happiness is the factor that contributes most to global adult personal satisfaction. In his extensive review, Waring (7, 8) has noted that "problems with intimacy constitute the largest single cluster of problem behavior for which outpatients seek psychotherapy." He found that 50 per cent of patients who seek psychotherapy do so because of marital difficulties and an additional 25 per cent have problems related to their marriages. The lack of a close, confiding relationship is a vulnerability factor in women who develop depression under adverse circumstances, and this lack is a factor in male depression. Also in the general population deficiencies of marital intimacy showed a significant association with the prevalence of non psychotic emotional illness.
If we can assume that the physician's marital difficulties are associated with the cluster of other problem behaviors to which he is prone, it would be helpful to determine what is unique about the marital problems of physicians. Also we need urgently to understand the frequent breakdown of physicians' marriages, and to discover "markers" for prevention or early treatment.
The focus of this paper on the physician as male is not meant to ignore medical women. In 1982, 16.5 per cent of physicians in Canada were female (9). The percentage of female medical students in Canada has increased steadily, from 7 per cent in 1957-58 to 42 per cent in 1983-84 (10, 11), and in some schools it has exceeded 50 per cent in some recent class years. In the U.S. the percentage of women earning medical degrees between 1970 and 1979 increased from 8.4 to 23.0 per cent, and in 1981-82 the percentage of women enrolled in first-year medical training approached 33 per cent (14). However, to date, little attention has been paid to the marriages of female physicians as a separate phenomenon and the literature contains little on this subject. A study (12, 13) of women physicians in Ontario in 1974 found that 64.2 per cent were married, and that the majority of these women did not feel that their practice had a detrimental effect on their home life. Only 13.6 per cent believed that their work adversely affected their relationship with their husbands. Of those who felt that their practice had a detrimental effect on their marriages and family life, the major conflict was around the issue of time - particularly for child-bearing and child-rearing. About one-third of these married physicians resolved their conflicting priorities by decreasing their practice time. A more recent study by Myers (14) reports that women physicians, while experiencing many of the same stresses in marriage as men, such as difficulty with time and intimacy, present patterns of conflict which are quite different at significant points. Women physicians suffer even more role conflict (between career and marriage) than men because of the more intense competitiveness required to maintain a woman in a male-dominated profession and because of the social norm that identifies her with the home and children. Despite this, Myers found that women generally succeed in balancing these roles better than do men. Unlike men, women physicians had trouble with self-image and assertiveness in their marriage and exhibited a paradox of career confidence along with unresolved dependency on their husbands. About 20 per cent of the women he studied described medicine as "alienating" and said it isolated them from other women and from the mainstream of the male population.
Often we define the dimensions of interpersonal relationships in terms of boundaries, power and intimacy. Of these, intimacy is held to be paramount. Alexander (15) offers this definition: "Intimate contact is that close contact between two individuals in which they reveal themselves in all their weakness without fear. It is a relationship in which barriers which normally surround the self are down. It is a relationship which characterizes the best marriages and all true friendship. We often call it love."
If a relationship between two human beings is to mature into intimacy, it must meet at least two conditions: (1) the people concerned must see each other often - almost every day, although not necessarily for long at each time; and (2) they must see each other under informal conditions, without the special overlay of role that we usually wear in public. Given these conditions, they likely will share the ultimate meaning of their lives as well.
An impressive body of work emphasizes the importance of the quality and quantity of interpersonal intimacy to marital adjustment, family functioning and psychosocial adaptation. Waring (7) identifies eight facets of intimacy:
• Conflict resolution - the ease with which differences of opinion are resolved;
• Affection - the degree to which feelings of emotional closeness are expressed by the couple;
• Cohesion - a feeling of commitment to the marriage;
• Sexuality - the degree to which sexual needs are communicated and fulfilled by the marriage;
• Identity - the couple's level of self-confidence and self-esteem;
• Compatibility - the degree to which the couple is able to work and play together comfortably;
• Expressiveness - the degree to which thoughts, beliefs, attitudes and feelings are shared within the marriage and as well, the couple's level of self-disclosure; and
• Autonomy - the success with which the couple gains independence from their families of origin and their offspring.
Using this operational definition, his studies tend to confirm the hypothesis that intimacy in marriage predicts marital adjustment, while lack of intimacy is associated with non-psychotic emotional illness and psychiatric help-seeking behavior.
In working with troubled medical marriages, we have observed that one of the biggest handicaps is the failure to develop an intimate relationship. For one reason or another the couple are strangers to each other. Some years ago the novel Not As a Stranger told the story of a married medical student and his wife who worked to help him through medical school. Then he found that he had outgrown her intellectually and socially. They had lived together, but they had not developed together: eventually he dropped her. That pattern is familiar but, in our experience, the actual break usually does not come until they are in their forties, when the "someday" of intimacy, which kept them going at first, never materializes. The physician's spouse accepts the hard work and loneliness of the years of medical school and tolerates the situation because she believes there is light "at the end of the tunnel." However, this does not come during the hard years of internship and residency. Immediately after that the physician becomes fully absorbed in establishing a medical practice and in wider medical activities. Finally, after he is well established, his wife finds that commitments to medical practice still do not decrease. It is then that she realizes that the hoped-for intimacy and sharing is a mirage. Often the wife feels that emotionally she has been a widow for years, and has had a husband who just wants to be looked after when he is home.
The lack of intimacy is not unique to physician marriages, but at least four factors combine to impose particularly difficult stresses on physicians and their wives: role strain; role conflict; susceptible personality type; and loss of self-esteem.
Within the medical environment, role strain can be defined as "the felt difficulty in fulfilling role obligations" (Goode, quoted in 14). The profession of medicine sets before its practitioners the highest ideals of service to humanity, and the stress intensifies, as each technological advance seems to increase the "miraculous" power of the physician and raise the social expectation of increased performance. Inevitably and realistically, the individual comes to the end of his resources and the physician recognizes that he has failed to fulfill his own ethical commitments and feels overwhelmed by society's expectations. In this connection, Shortt (4) cites an Australian study, which showed that physicians in clinical practice were significantly more anxious than nonclinical physicians, and that their anxiety was directly connected to fears of inadequacy in fulfilling the professional role.
In a related way, the physician is caught between his altruism as a healer and his needs, as a self-employed entrepreneur, to operate a "business" in the face of escalating expenses and increasing governmental controls. Paradoxically, the freedom of being self-directed imposes great strain. Physicians in private practice attempt to respond to infinite needs, wants and demands without any clear-cut limits to their responsibilities. They have to set their own limits on time and responsibility. In contrast, most occupations have a definite time-frame for work and a realistic standard of performance, which the public recognizes and accepts.
These role strains, ambiguous demands and the lifestyle imposed on the physician invite him (or her) to "cop out" when marital tensions develop. Properly faced, these tensions could lead to sharing and intimacy, but instead physicians may become more deeply involved in professional activities, which bring greater social admiration but less responsibility at home. Unlike lawyers, who respond to stress by reducing their activity, physicians typically respond with more activity (16). This response aggravates the problem at home while failing to meet the physician's own and his spouse's need for intimacy. Frequently, when the physician does come home for respite, it is to recuperate from exhaustion rather than to contribute energy and life to the marriage. We need to recognize that one factor common to professional "burnout" is the professional's excessive level of aspiration.
A second factor is role conflict, that between the professional and the marital roles. The highly competitive selection system guarantees that those who get into medical school will have an abnormally high tolerance for delay of gratification and will be capable of sustained effort without immediate reward. They are likely to be self-critical and often critical of others. From medical school on, the professional role requires technical excellence and singlemindedness, an intelligent, logical, unemotional approach to life, combined with a capacity for hard work. As Sargent (17) has noted, this environment may suppress other less-valued traits, such as capacity for interpersonal warmth, generosity, gregariousness, emotional flexibility, and the ability to shift gears from high output to relaxation and selfindulgence. These traits are those needed for effective functioning in that other demanding system to which most physicians belong - the family. Thus it appears that the characteristics that enable high performance in medical school may handicap the individual in the family system.
Here is the core of the conflict between the values and personality traits needed by the "good" physician and those needed by a good spouse and parent. The good physician can control his or her feelings. A good spouse shares feelings. A good physician works hard; a good spouse and parent is available for companionship. A good physician usually has the following needs: success, status, prestige, professional esteem, and money; yet the fulfillment of these needs demands time away from the spouse and parent relationship. Thus the physician is pulled in two directions: patients want a physician who is available, current and good-humored; families want a spouse and parent who is available, helpful and good-humored.
The conflict is not entirely explained as competition for time. Many other professions are time-pressured and success- and money-oriented. Instead, the central issue seems to be the conflict between the typical "physician" personality and the personal qualities needed for intimacy within the family. Intimacy suffers when the physician brings clinical detachment into the marital relationship. As Fowikes (18) noted, for example, when a physician treats his own family, usually he operates with his professional, rather than his personal, self; he is calm, detached and impersonal. She concluded that the structure of medicine makes the curing and caring roles mutually excusive. In a study of the medical care received by doctors' wives, West (19) found that these wives considered their medical treatment far inferior to that given the general population, and that the husband projected his medical role into the marital and family relationship: "Wives who succeeded in attracting their husband's attention to their medical problems at home often found their husbands treating them as a doctor rather than as a sympathetic husband." Others said that their husbands confused the patient and wife roles. It seems that physicians, because of their personality and their training, tend to overemphasize the objectivity of medical practice, and undervalue the importance of human relationships and the mutual meeting of personal needs in close relationships.
A third factor in the physician's struggle for intimacy is the individual personality. Typically, studies of breakdown of medical marriages describe the physician's personality in such terms as "cold," "distant," "rigid," "uncommunicative," and "undemonstrative" (4, 5, 16). Miles et al. (5) reported that physician-husbands tend to be "professionally competent and successful, but to present as rigid, interpersonally distant and covertly or overtly controlling. They are extremely uncomfortable with feelings, whether of love and tenderness or hostility." They go on to describe a basic pattern in physicians' marriages: "A dependent, histrionic woman, with an inordinate need for affection and nurturing, [marries] an emotionally detached man. The fact that he is a physician, seen by society as the ultimate in caring, may have much to do with the wife's choice of a husband."
Undoubtedly the individual often learns to suppress emotion in the course of medical training. A physician learns to remain calm in the midst of crisis, and learns, like Rudyard Kipling's hero did, to keep his head while all about him are losing theirs. As a matter of proficiency and survival, physicians must distance themselves from suffering, although often they move from over identification to aloofness - completely missing the experience of empathy. However, some research workers find that the emotionally detached personality that we associate with physicians has roots which predate medical school. There is evidence that problems in early-life adjustment have rendered some physicians susceptible to emotional and marital dysfunction. Vaillant et al. (2), for example, say "barren childhoods" or "overprotective parents" make physicians vulnerable when they are overburdened with demanding, dependent patients, and find that only physicians with the least stable childhood and adolescent development appear vulnerable to the occupational hazards. When they compared the median age at which lawyers and physicians first sought marital therapy, the Isbisters (20) found that physicians came much later, and also presented "more chronic and intransigent marital problems - as if at the end of yet another ultimatum"; and that doctors were less comfortable with the therapist's challenges for change. This suggests a personality that has accommodated to a long-term pattern of emotional deprivation, to whom intimacy may seem to be a great deal of hard work, if not impossible.
Finally, in both the physician and the spouse loss of self-esteem contributes to the difficulty in intimacy. In modern society, physicians may have lost some of their earlier elitist position. In any event they were not always highly regarded. In the late nineteenth century, Daniel Gilman, President of John Hopkins University, said that "one son of the family too weak to labor on the farm, too indolent to do any exercise, too stupid for the bar and too immoral for the pulpit, went into medicine" (21). However, by the end of that century, 28 per cent of all college graduates went into medicine, and physicians held an honored and unique place in society, being regarded as highly educated, concerned and caring professionals. Today, some segments of society regard physicians as businessmen engaged in union-like activities - an important part of the high-earning health establishment. Some even suggest that physicians are bad for people's health; that they overoperate, overprescribe, and attempt to deal with all of life's problems in medical terms. They get more media attention from malpractice than from good practice. In response to this inimical environment, many physicians work harder, with greater commitment to their patients and to the profession, at a cost to personal life which they may see, too late, is too high.
The spouses of physicians also feel the loss of general public esteem for the profession. As wives, they may be anonymous and forgotten in modern society, where not long ago they would have been visible and highly regarded. More tragically, however, many wives feel unneeded by their physician-husbands, who still get psychological support through work and public recognition. Thus, some physician's wives feel they can add nothing to their husband's welfare and self-esteem. At the same time the physician has not taken enough time to show his wife that she is important to him. The deflated wife may complain that she is nothing but a cook and prostitute, while the deflated husband may complain he is nothing but a breadwinner. When we ask doctors' wives if their work is as important as their husbands', the usual reply is "no." Few believe that their husband's professional achievements depend on or require their support. At a time when society is withdrawing its respect for both physician and spouse, each has even greater need for the appreciation of the other.
PREVENTION AND TREATMENT: Some measures for prevention and treatment may be summarized as follows:
• Physicians must take responsibility for their own decisions, for shaping their own lives, and for setting limits accordingly. If they desire marital satisfaction and personal health, many may need to work out a shift in values and accept a reordering of time and attention; in all this, they must give development of intimacy a priority position. We need to be convinced that an intimate marital relationship gives substantial rewards, both personally and professionally.
• Physicians need to be fully aware of their own vulnerability and that of their colleagues. Through its publications, associations and schools, the profession must encourage doctors to accept that vulnerability by encouraging them to seek help for personal and professional needs without stigma. We need ongoing peer support groups and growth-oriented programs for physicians, their spouses and other health-care professionals. The physician, spouse, medical training institutions (and society itself) can all give greater support to personal and family life.
• The technological effort, which has brought great advances and has dominated medicine in recent years, has to be brought into balance with the human dimension. Unassisted, the individual cannot bring about that kind of values shift; what someone called medicine's "human condition seriousness" (1) will continue to make technical excellence a non-negotiable priority. However, if. human beings are to function as healers within a highly technological system, the healing process must be seen as something more than the application of machines, techniques or drugs. Both patient and physician need to appreciate that it involves relationships, the fulfillment of personal needs, and feelings. The re-emergence of family practice may represent that shift. Any movement that would take the person as seriously as the symptom would encourage the physician who chooses to do so to develop his/her personal relationships.
• As Gerber (1) notes, the growth of the patient advocacy movement and the appearance of books like those by Norman Cousins show that many patients are anxious to take responsibility for their own medical care, in consultation with the physician. If physicians can accept this new model without concluding that it sacrifices medical standards, they may gain in the patient a highly motivated and responsible partner. This new alliance promises to ease the physician's burden of excessive responsibility and isolation.
• Physicians and spouses should be encouraged to seek help for marital difficulties early, before the breakdown becomes chronic. The treatment of choice is marital or family therapy, which encourages individual growth within the context of changing the family or marital system, rather than individual therapy which tends to increase the separation of the partners. Glick and Borus (22) report that marital therapy with some concurrent individual therapy produced substantial improvement in more than 92 per cent of the physician marriages they studied.
• For the sake of marital intimacy, the physician needs to find a balance between self-sacrifice and self-nurture. "Cherish thyself" is a good motto for the physician's own health. When he/she recognizes the need to care for his/her own personal needs, both his/her marriage and his/her effectiveness as a physician will benefit.
SUMMARY: The goal of marital adjustment is to achieve self-fulfillment for both partners without sacrificing the self-fulfillment of either. The aim is not just fulfilling two separate individuals but finding fulfillment in relationship. This achievement - referred to here as intimacy - appears to be particularly elusive for physicians. This paper identifies four factors which contribute to the physician's difficulties with marital intimacy: role strain - "the felt difficulty in fulfilling role expectations"; role conflict; susceptibility of the "physician" personality; and loss of self-esteem. The nature of professional commitment produces idealism and anxieties around medical-role expectations; these militate against creative involvement in marriage and drain energy from the marital relationship. The conflicting priorities of professional and marital roles and the very different attitudes required for scientific objectivity and personal encounter (intimacy) call for a flexibility that many physicians are unable or unwilling to exercise. The physician's high-functioning, objectifying personality, which selected him for medicine, may suppress the very intimacy needed in marriage. In some cases, deprivations or difficulties in early life adjustment may render some physicians vulnerable to marital dysfunction. Finally, the medical profession is suffering a loss of esteem, which removes a reward that previously had given its members a secure social place and had compensated physicians and their spouses for marital sacrifices. Some measures for prevention and treatment include encouragement to seek early treatment; the setting of limits and priorities between career and marriage; a valuing of the rewards of intimacy; the removal of stigma for seeking marital therapy; a healthy compromise between self-sacrifice and self-nurture; and a balancing of the technological and human dimensions of medicine.
Merville 0. Vincent, MD, CM, MRC PSYCH, FRCP (c)
Executive Director
The Homewood Sanitarium
Guelph, Ontario
George R. Slater, STM, PH D
Pastoral Counsellor and Psychotherapist
Toronto and Waterloo, Ontario
