The Contribution of Demoralization to End of Life Decision Making

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The Contribution of Demoralization to End of Life Decision Making

 
 
   
Some psychiatrists believe that "demoralization syndrome" is a diagnosable cognitive disorder characterized in its extreme form by morbid existential distress. If they are right, then it should be an important part of our thinking about end of life decision making. A demoralized patient would be unable to think reliably about the remainder of her life, and therefore incompetent to decide to commit physician-assisted suicide.

The pointlessness of a wretched existence, in which meaning and purpose are lost and despair is pervasive, can lead to a wish to die. This mental state may develop in association with the suffering of the chronically medically ill and of the dying.

Should a plea to hasten dying be viewed as a rational request for merciful assistance, or is it symptomatic of a suicidal mind disordered through illness and warranting a therapeutic response? Out of the clinical and ethical debates about end of life decision making, a fundamental question has arisen: is demoralization no more than a comprehensible human and emotional response to a state of dire bodily disease, or can it be a pathological process deserving of diagnosis as illness?

In this paper, I explore demoralization as a "dimensional" state of mind--that is, as a mental state ranging from a normal response to perceived helplessness to a morbid form of existential distress. The impact of demoralization upon a person's capacity to give informed consent across a range of end-of-life decisions is a pivotal question. Demoralization influences a person's "assumptive world" and may, as I shall show, interfere with his appreciation of clinical data pertinent to decisionmaking. Clinical and legislative implications arise when severe demoralization is recognized as a morbid state of mind.


Acceptance of Dying

No argument exists concerning the capacity of people to accept rationally the reality of their death. Indeed, sociologists have described this as a quest of the modern palliative care movement: to help patients face their dying with open awareness and courage, the 'ideal' of a heroic death in the supportive care of their family, friends, and community. (1) This acceptance of dying is commonly identifiable within the narrative of many patients, especially the very elderly, as they anticipate what their future might hold. The following clinical account helps to illustrate their mental state.

Couples on the Brink: Stopping the Marriage-Go-Round
Let’s face it, psychotherapy isn’t dramatic, and most therapists don’t rate high on a “need for thrills” scale. Someone unfamiliar with our craft might even say that not much happens in therapy sessions: people talk about their problems; we listen, ask questions, and drop in observations and comments. At the end of the hour, clients thank us, pay their bill, and go home. Next session, we repeat the process. No wonder screenwriters feel they must put gangsters on the couch or show psychiatrists like Barbra Streisand who fall in love with clients like Nick Nolte. Ours is low-key work that’s a big yawn to the uninitiated, and to tell the truth, sometimes even to us.

No apologies here for being mundane. Dr. Phil aside, we know that good therapy chips away at problems, building trust and helping people rewire their brains and their relationships synapse by synapse and conversation by conversation. In most kinds of therapy, we don’t often deal with decisions of immediate consequence. Our clients don’t noticeably recast their lives after leaving our office on any give week--they get better the way the old joke says a musician can get to Carnegie Hall: practice, practice, practice. 

But it’s different when clients talk about their marriage problems. A life-changing decision is frequently on the table--whether to stay in the marriage or leave it. People make this decision during or right after a therapy session, and their lives are forever altered, along with the life trajectories of their partners, their children and parents, and often many others. Even when a divorce is necessary and constructive, it ends a dream and, in the words of the social historian Barbara Dafoe Whitehead, marks the death of a small civilization. 

In the crucible of psychotherapy with people on the brink of divorce, what we say has a real impact on people’s lives. But most of us have been taught the fiction that we aren’t influencing these decisions, or, in any event, shouldn’t be influencing them, even though we do so with every word we utter, every time we’re silent, every expression on our face. The result is that the most life-altering matter we deal with in therapy, short of suicide, is one we don’t talk about much as therapists, don’t get training in, and pretend we don’t need to develop skills for. 

Marriage and divorce are hard issues to talk about in our field right now. The marriage culture wars are in full swing, and everyone is expected to take a side. The Right gets upset if you’re pro gay marriage (as I am), believing that you couldn’t really be for marriage in that case. The Left gets upset if you “privilege” long-term commitment in that patriarchal institution--heterosexual marriage--believing you must be the dupe of the Religious Right. As a longtime liberal, I feel a bit of whiplash when I talk to both sides. Why can’t a nice, NRP-listening, Planned Parenthood-contributing, Unitarian Universalist liberal like myself be a fan of committed, lifelong marriage, straight or gay, knowing that not everyone will choose marriage and that some marriages, unfortunately, can’t stay the course? The truth is, it took me a long time to come to this both/and stance, and it sometimes leaves me without a tribe. 


The Objectivity Myth

I don’t know about you, but as a young therapist, I learned to treat the divorce decision with pseudo-objectivity. I remember working with Mary Ann, a 35-year-old woman in an unhappy marriage who wanted individual help to decide whether to keep working to change her marriage or end it. She and her husband had two small children. This was the height of the divorce boom in the 1970s, and a number of her friends had recently left their husbands. 

Mary Ann felt stifled in a bland relationship with a man who didn’t connect with her emotionally in the way she wanted, and who expected her to do the lion’s share of the parenting and housework, along with her part-time job. Sound familiar? As I sat with her, I realized that I’d never been taught how to work with someone on the brink of divorce. My training in marriage therapy started with the assumption that both parties wanted to stay together, at least for the time being. My training in individual therapy had taught me that my job was to help my clients clarify their feelings, needs, and goals, and then make their own decisions without my own values and viewpoints getting in the way.

So I did a kind of rational-choice consultation with Mary Ann, helping her clarify what she’d gain or lose personally from her choice. “How would your life improve from leaving your marriage,” I asked, and “What might it cost you to leave?” The same for staying--“What are the pluses and minuses of remaining in the marriage?” (I was studying statistics at the time, and even imagined a two-by-two contingency table!) When she worried out loud about the effects of a divorce on her kids, I responded in that oh-so-’70s way: “The kids’ll be fine, if you’re happy with your decision.” Mary Ann ultimately decided to file for divorce and start a new life.

Even at the time, I felt odd about treating this client’s dilemma as if it were a decision that only affected her. And I felt sad that another marriage was biting the dust. Not that I’d have admitted this to a supervisor or peer, because a hallmark of a good young therapist was to be cool about the rash of divorces we were seeing among our clients and friends--no one wanted to come across as a bleeding-heart marriage saver. Divorce was a hard-won right and a legally supported, no-fault, personal choice. Common wisdom was that a therapist shouldn’t get too involved, beyond clarifying and supporting the client’s autonomy. 

Looking back, I’m struck with my naiveté about what’s involved in leaving a marriage, especially one with children, and my innocence about my lack of influence on the outcome. Mary Ann, like most people facing this decision, was caught in a morass of ambivalent feelings and values. She’d made a lifelong commitment to her husband, and now was considering withdrawing it. She wondered whether her expectations for this husband, or any husband, were realistic. She hadn’t done much work on herself, therapeutic or otherwise, and didn’t have much of an idea of what good marriage therapy might accomplish. She worried about her own economic future, and she was deeply concerned about the effect of a divorce on her children, who’d lose their daily connection to their father, take a financial hit, and face a series of substantial life changes. She also believed her parents and her friends would be shocked and upset with her if she left the marriage. 

Mary’s journey toward her decision was, like most people’s, highly unstable and ambiguous. In spite of the high stakes involved in the decision, both for herself and her family, however, I treated her as if she were thinking of changing jobs from Walmart to Target: what does each company offer you, and what would each take out of your hide? Does anyone really believe that I didn’t influence her decision by what I inquired about and what I remained silent about? When I arrive in that great therapy afterlife, where all issues have been resolved, Mary Ann is on my list of former clients I’ll look up to say, “I’m sorry. I could have done better.” Maybe her decision was the best one and maybe she would have made the same choice regardless of how I’d worked with her, but she deserved a complex therapy to match the complexity of her dilemma, not the oversimplified therapy I offered with my neutral, objective stance. And so did her husband and children and future grandchildren.

I’m not just talking about a therapy that gets more deeply into clients’ psychological dynamics and history. I’m talking about a therapy in which therapists walk with their client through the moral dilemma of whether to end a marriage that’s accumulated many stakeholders through the years, and in which therapists accept responsibility for the influence they’ll inevitably have at these moments. We’re midwives for the deaths and rebirths, the shattering and rebuilding of intimate relationships that are at the heart of human experience. But you won’t find much training, writing, or even conversation among therapists about how we handle these moments in therapy. The result is that we’re each left to develop a therapy approach on our own, and often the results aren’t pretty. 


When Words Carry Unintended Meaning

I don’t know any therapists who are against marriage and lifelong commitment. In fact, most therapists are married themselves. They have sophisticated ways to talk about most relationship issues. But when it comes to decisions about divorce, many therapists sound fairly simplistic, using catch phrases and truisms that carry messages they may not intend, believe in, or practice in their own lives. Here are the three top catch phrases I’ve heard therapists use through the years:
  • I’m not here to save marriages. I’m here to help people.” I know therapists who say this on the phone to prospective clients who are calling to ask for help with a spouse who’s threatening to leave the marriage. They also say it to couples during the first session. The phrase has a surface wisdom: we aren’t saviors, and a relationship that’s destructive to individuals shouldn’t be preserved simply because it’s a marriage. But drill down deeper into the phrase and you find a dichotomy between the individuals and their committed relationships, as if personal well-being is something completely aside from the health and stability of family relationships. 

    Our core selves don’t float free of our committed relationships; a marriage is part of who we are, not something we put on or shed like an article of clothing. Therapists know this, of course, but they risk sending the message that marital commitment should be way down on the priority list from strictly “personal” goals when they make such a statement. What’s worse, they probably think they’re uttering a truism, and that they’re being objective and neutral. Save us from our delusions of objectivity and neutrality!
  • “You need to ask yourself if you think you’ll have a better life in the future if you remain married, or a better life if you end the marriage. I can help you stay together well or part well, depending on what you decide you want.” I remember the time and place when I heard a very experienced therapist mention offhandedly that this was his standard line with couples considering divorce. I looked around the roomful of therapists and saw heads nodding in respect for the wisdom of this clear-headed, senior therapist. That was the moment when I realized that case consultation, not books, articles, or training workshops, is where practicing therapists create our shared realities, the taken-for-granted norms of our work. 

    At first blush, this therapist’s standard line seems obvious and straightforward. But as the frame for the divorce decision, he’s sending three powerful messages. First: “Don’t think about your original commitment to your marriage, or about good years in the past, or about the needs of anyone else in your lives.” Second: “I personally don’t care whether your marriage survives or dies.” And third: “It’s a fairly straightforward decision; why don’t you make it promptly and we’ll get on with our work?” The case consultation moved on to other topics and I didn’t speak up about my concerns about the “better life” phrase. I would now though.
  • There never was a marriage here.” This is what Tom and Beth’s therapist told them after two sessions of couples therapy. They’d gone for therapy because Beth was disillusioned over the decline of their relationship in the two years after their first child was born. They both came from troubled families and had married young. Tom had been on drugs when they met and eventually cleaned himself up. Beth had been his caretaker then and remained so until their child was born, after which she focused on the child. Reeling from losing his wife’s undivided attention, he’d had recently tried crack again. 

    Tom wanted to save the marriage, and not repeat the fracturing that had taken place in his own family. He feared losing contact with his child, as his father had done with him. Beth had gone through a wicked postpartum depression and received some personal counseling that helped her see how she’d carried her sense of over responsibility from her family of origin to her relationship with Tom. She was thinking increasingly of divorce, but was worried about breaking up the family.

Tom told me that, after getting their history, their couples therapist told them that they’d never been “really married,” due to their youth and the problems they’d brought to the marriage. This pronouncement got Beth’s attention, since it fit in with what she’d learned in her individual therapy and in the self-help books she’d started reading. If there had never been a marriage, she thought, then why try to create one now? Would she have even married Tom if she’d been as smart then as she was now? No way! Beth promptly ended couples therapy and started divorce proceedings. Tom felt bushwhacked by the therapist, but didn’t understand why.

Like other therapist catch phrases, “there never was a marriage” has an obvious appeal. Many marriages are contracted for loads of unhealthy reasons. But when therapists pronounce a marriage dead on arrival, despite the fact that the wedding was a decade ago and now there are children and a mortgage to contend with, they risk further demoralizing the spouses--“Why should we try, if we never started out right?” If one of the partners has a honey on the side who looks like a candidate for a real marriage, they feel encouraged to deep-six the current faux marriage. Of course, a future therapist may pronounce the new marriage stillborn because it began in an affair. Let’s face it, we therapists are clever enough to find the original fatal flaw in nearly any marriage that presents to us in trouble. By our steely standards for differentiation, intimacy, and equity, there may not be one “real” marriage in America. As one wise soul said, “There are grounds for divorce in every marriage; the trick is to find the grounds for staying together.”


As I began to compile therapist catch phrases about marriage and divorce, I noticed that each has an unbalanced wisdom because it comes down too heavily on the side of individual self-interest--not surprisingly, given psychotherapy’s culture of individualism, they don’t take into account communal values of responsibility and obligation. Each saying also assumes people are making calm, rational decisions, instead of being tossed about in a storm of emotional distress, ambivalence, demoralization, and poor brain functioning. The standard phrases would fit better with a decision to leave a job: “Do you think you will be better off staying with this company or seeking new opportunities? You know, it seems like this job never was a good fit from the beginning. And I don’t have a stake in whether you stay with Microsoft or leave for Apple.”

But if the therapist uses language that equates ending a job with ending a marriage, what’s a client to think? What’s the therapist saying about a commitment “for better or for worse”? Often a demoralized spouse, or one with a better marital prospect waiting in the wings, will take something a therapist says as encouragement to leave. Maybe they should leave, but I doubt that the therapist is conscious of tilting the decision so decisively. What we don’t know about our influence can be dangerous.

Making Your Meaning Clear
What’s the alternative? Some therapists fear that if they surrender their neutral stance, they’ll have to start telling people that they should stay married. So it’s important to know how to lean toward commitment without being prescriptive, judgmental, and invading our clients’ autonomy. Here’s alternative language for talking with clients. Some are phrases I use myself, and some I’ve gathered from therapist colleagues. 
  • As a marriage therapist, I lean toward helping people find a way to live out their original commitment to each other, if that’s possible. I know it isn’t always possible, and it’ll be your decision. But I like to help couples see what might be possible for their marriage before they call it quits.
  • There’ll always be time to divorce, but there may not always be time to save your marriage. 
  • The issue right now isn’t whether you’re committed for life, but whether you can commit to working hard to salvage your marriage in therapy, with divorce off the table for the time being.
  • I can see that your hope for your marriage is very low. I see my job as holding that hope for you for a while, until you see whether it’s possible to rebuild your relationship. 
  • Unless a couple has tried an all-out effort in therapy to save their marriage, I myself am never convinced that a marriage isn’t salvageable.
  • If you haven’t yet worked on changing yourself, it’s a bit of a cop-out to say that your marriage is hopeless because your spouse will never change. 
  • I’ll be working for your marriage until one of you looks me in the eye and calls me off.
These commitment-affirming statements can have the same degree of influence on clients as the “neutral” statements, with the difference that the therapist knows that he or she is speaking from a value-based position, as opposed to just stating “objective” truisms. When I make statements like these, I’m consciously advocating for the marriage. Since I acknowledge the impact of my procommitment values, I make an effort to balance my stance by also eliciting and listening empathically to my clients’ sense of demoralization and despair about their marriage, and by pairing autonomy-supporting comments with marriage-supporting statements, such as: “Knowing that it’ll be your decision to make, not mine, I want to let you know what values I bring to our conversation.” 

Cheryl had been married for 17 years and had two teenage children. About a year before our consultation, which was requested by her therapist, who felt stuck with the case, she’d begun an affair with a man she knew professionally, and was paralyzed about making a decision of whether to stay in her marriage or move in with her lover. Her job took her out of town about once a month, when she and her lover got together for great sex and conversation. Her lover had started divorce proceedings with his wife, and was pressing Cheryl for a commitment to leave her husband and be with him.

I asked about her marriage. She said that her husband was a very good man--kind, loving, and supportive--but that the marriage lacked passion for her. She’d felt emotionally empty for a number of years, and their sexual relationship had become infrequent and unexciting. They were doing a good job of raising their children, she thought. Her husband had supported her career decisions. In fact, he was so supportive and constructive that she was confident that he wouldn’t abandon her or be mean spirited if she told him about the affair. 

But, she said, she deserved more out of life and marriage than she felt she could get from her husband. It was fear of hurting her children that was keeping her from leaving. They’d be devastated, she thought, and their lives would be turned upside down, especially if she moved away to be with her lover. 

Cheryl described the decision she was facing as a “churning dilemma.” After years of passively accepting a loving but passionless marriage, she felt that she’d come alive after being kissed by a man who’d been her friend, only to become her lover. 

As I listened to Cheryl tell her story, I concluded that hers was not an abusive or destructive marriage, but rather a supportive and companionate one that seemed to be meeting many of the needs of the children, her husband, and even Cheryl. If she’d told me her husband was violent, addicted, or chronically irresponsible, I’d have thought about her situation differently, because sometimes an affair is a wake-up call to seriously consider getting out of a destructive marriage. Instead, my value about moral commitment in marriage permeated my consultation. 

I saw Cheryl as operating out of what I call a “consumer” approach to marriage--focusing on what benefits she wasn’t receiving from her husband, and not on what she was failing to put into the marriage. And I believed there’d be serious harm to her children and to her husband if she were to end her marriage at this point. As I listened to her, I reflected on the recent research demonstrating that the children who experience the most harm from divorce are those whose parents have relatively harmonious marriages, even though they may not be happy or intimate marriages.

Cheryl struck me as a good, sensitive person, but she spoke about her personal desires as if they were Constitutional rights, like freedom of speech, and her emotional needs as if they were biological facts, like needing vitamin C to avoid scurvy. Our culture teaches us that we’re all entitled to an exciting marriage and great sex life; if we don't get both, we feel deprived, and permitted to go elsewhere to meet our needs. What used to be seen as a weakness of the flesh has mutated into a personal entitlement.

Although it lurks inside nearly every married person in our mainstream culture, the consumer attitude usually doesn’t become apparent until we come face to face with our disappointments about our marriage and our mate. Then we start to ask ourselves, “Is this marriage meeting my needs?” and “Am I getting enough back for what I’m putting into this marriage?” In Cheryl’s case, she’d told herself for years that she’d “settled” for a second-class marriage for the sake of the kids.

During the first 20 minutes of the interview, I focused on helping her examine the implications of leaving her husband for her own well-being. Using the metaphor of the affair as a vacation paradise where no one can actually live permanently, I tried to undermine the fantasy of a blissful new love relationship that would never encounter the erosion of passion that all long-term relationships must face. I also presented a scenario in which she could see rebuilding her marriage as a positive option for herself, instead of a sell-out of her core personal needs. Since she’d eventually end up on the “mainland”--in a long-term relationship, with its daily responsibilities and challenges--anyway, why not figure out how to have a satisfying marriage with her current husband, I asked. She clearly preferred that option, but was doubtful that it was possible.

Toward the end of this part of our conversation, Cheryl explicitly said that she’d consciously chosen the affair and was no longer “a good girl.” I know how I’d have handled this comment during the 1970s: I’d have encouraged her to challenge the way society, or religion, or her rigid conscience were defining her as no longer “good.” I’d have supported her heroic efforts to break out of the mold of following other people's expectations for her. 

Instead, I let her remark pass without comment or follow-up. I wanted to move the conversation to the realm of interpersonal morality--how her behavior and decisions might affect others in her life--rather than focusing on her claims to authenticity and rebellion from conventional standards. Future therapy could return to the theme of her being a good or bad girl, to see if she could integrate these parts of her identity, but for now, I wanted to shift her gaze outward rather than inward.

In a pivotal part of the interview, I summarized and validated the aspect of her decision associated with her personal self-interest, and then asked her to reflect on the consequences of her leaving. 

“Okay. So there are two parts of this,” I said. “One part is where you might have your best chance for personal happiness--to live in this new relationship so that the next part of your life may give you more joy. And then the other part of that decision concerns the consequences to different people.” 

“Yes, I know, I know,” she responded.

“So let's talk about that part of it.” 

“The consequences?” Cheryl asked.

“And maybe we can put your personal happiness and the consequences for others back together at some point. But, for now, how do you think a divorce would affect your children?” I asked.

“Oh, the consequences would be devastating,” she admitted.

We explored her sense of those consequences, and I affirmed my concern as well. 

The next key moment in the interview followed my statement that it’s possible for couples who work at it to “have the kind of energy and passion that’s truly fulfilling--not the same as that of a new relationship, but the kind [of passion] that, after 10 years or 15 years or 20 years, you say, ‘Wow, this is good.’” 

“Yeah, see, I can’t believe that,” Cheryl replied. “It’s unbelievable to me that that’s possible.”

“In your marriage?” I queried

“In my marriage, right,” she said. “So, keep talking, so you can tell me more how to do that.”

At this point, I had permission to lay out a path in which Cheryl would end the affair definitively, and proceed to tell her husband that their marriage had been in grave danger and that she’d had an affair. A little later, when she challenged the idea of telling her husband about the affair, I said that I don’t have any rules about this sort of thing, but that my sense was that this level of honesty would give her husband and her their best chance to make some major changes. 

During the remainder of the interview, I tried to undermine Cheryl’s sense of fatalism about the likelihood that her husband could change. I did this by challenging her own passivity in the marriage and her unrealistic beliefs that, somehow, her husband should respond with grand, dramatic, romantic actions to her ambiguous, half-hearted gestures toward improving their relationship. Near the end of the session, I repeated the theme that Cheryl, at some point in her life, would have to do the hard work of maintaining an intimate marriage, even if she left her current marriage for her lover.

“So I might as well do it in my marriage, since we’ve got history in the marriage, and it would be hurting so many people for me to leave,” she responded.

“That’s for you do decide," I said.

“That’s for me to decide, yeah,” she agreed.

“But that sure makes sense to me,” I concluded.

Notice that I reaffirmed her autonomy in this important decision. I also quietly affirmed the direction in which she appeared to be leaning, since my position was no doubt quite clear to her anyway. I then encouraged her to work through the decision with her therapist. 

Cheryl ultimately took back her marriage. She ended the affair and started working on her relationship with her husband. Not without sadness, though, about letting go of the dream of a new relationship that would be a permanent love affair. An emotional crisis with one of her children also helped to rivet her attention back on her family. She regained her marital commitment when she understood what was at stake--a long-term marriage, a husband who loved her, children who depended on that marriage, and a community of people affected by the marriage. She’d been focusing on what she wasn’t getting from her marriage, what she was entitled to get, her husband’s flaws that had created her dissatisfaction, and how she’d be happier with a new model of husband. In the end, she came to see that she held citizenship papers in her marriage and only a tourist visa in her affair. Five years later, both she and her husband have made changes, and the marriage is doing well.

Some therapists might have worked with Cheryl in a different way, but my experience in showing the videotape of this session is that many therapists agree with how I handled it. They see her as potentially throwing away a decent marriage for a fantasy relationship. This case is on one end of a continuum of a promarriage stance. On the other end would be a case in which one spouse exhibits scary and controlling violence or abuse. Confronting such a case, most therapists would be very cautious about starting couples therapy and probably support separation. Then there’s the vast territory between the frivolous divorce and the destructive marriage. It’s the territory between these extremes where we differ so much as therapists, and it’s this ground in which the therapist’s personal values and professional orientation make a big difference in how we approach distressed couples at a high-stakes moment in their lives. 
http://tinyurl.com/yc6y75yWhen Is Enough Enough?
The key question in having a promarriage stance is how hard are we willing to work to keep people in therapy to restore their marriage, versus how ready are we to withdraw our active support for their relationship? This withdrawal can take many forms--voicing neutrality about whether the marriage endures, accentuating flaws in the relationship, empathizing more with the despair than with hope expressed by the couple, and focusing on individual unhappiness far more than on relational responsibility. 

It’s no doubt obvious by now that I tend to work long and hard with nearly all couples to help them see the possibilities for a renewed marriage, knowing that it’s their decision whether to stay or leave, to work on the marriage or forget about it. I look for hidden strengths in their relationship that they don’t see. I emphasize the high stakes when children are present. I try to buy time in which they can take a deep look at their relationship and what they’ve put into it, before they decide to call it quits. 

I know a lot of therapists who share my don’t-give-up-too-soon orientation, and a lot who don’t. We don’t have a consensus in the field about how hard a therapist should work when one or both partners is ambivalent about staying married, or when the relational problems are severe but not personally dangerous. When a spouse is having an affair, how much should the therapist encourage the offended spouse to move on versus hang on, keep healthy, and wait for a shift in the spouse or the other relationship? For me, nearly all marriages, including those marked by sexual or emotional betrayal, are worth going the extra mile for. Even if the marriage ultimately ends, spouses who work hard in therapy can learn a lot about themselves that’ll help them in the next phase of their life. 

Although I never tell a couple that their marriage is hopeless (that would be playing God), there are times when I stop supporting the marriage in couples therapy. The most common scenario when this happens is when one partner has made a decision to end the marriage, shows no ambivalence, and is proceeding inexorably with the divorce. Even if I think the marriage might have been salvaged, in situations such as this, I don’t try to keep both parties in therapy to work on their marital relationship (although we may work on coparenting). I remain supportive of the other spouse who might not be ready to give up on the marriage. It takes two to make a marriage, and one to end it. I don’t get a vote in either case.

In much rarer cases, neither party is talking divorce, but I don’t offer or continue couples therapy. These tend to be situations in which one partner refuses to take any responsibility for the problems and insists that the other do the changing. I recall a angry, “dry alcoholic” man who took the stance that he wouldn’t work on the marriage until she allowed him to move back home, even though he’d made their home life hellish before treatment, and she said she wanted to rebuild trust first. After two sessions of trying to get a contract for marriage therapy, I saw him and his wife separately, rather than pretend we were doing couples work. I empathized with his feeling of rejection and challenged him about his way of tying to reconcile with his wife. I told him I wouldn’t reinstate marriage therapy unless we had a three-way agreement that everyone would work on changing himself and the relationship. He didn’t buy it. She decided to end the marriage, and I supported her decision. 

I sometimes tell friends (and occasionally even clients) that I inherited the optimistic Irish genes, not the depressive one. I’ve seen the worst marital situations turn around, when people firmly committed themselves to personal change. I’ve seen irresponsible men start taking responsibility for their behavior, when confronted with the likelihood of losing their family. I’ve seen nearly out-the-door women realize that they could have a good-enough marriage and a safe home for their children, if they didn’t expect their husbands to meet all of their intimacy needs. Sometimes the couples don’t change dramatically but, in the words of one woman, they “outlast the problems” through stubborn perseverance--and that seems to be plenty good enough. 

I now think of long-term marriage like I think about living in my home state of Minnesota. You move into marriage in the springtime of hope, but eventually arrive at the Minnesota winter, with its cold and darkness. Many of us are tempted to give up and move south at this point, not realizing that maybe we’ve hit a rough spot in a marriage that’s actually above average. The problem with giving up, of course, is that our next marriage will enter its own winter at some point. So do we just keep moving on, or do we make our stand now--with this person, in this season? That’s the moral, existential question we face when our marriage is in trouble, and the crucible of psychotherapy with couples on the brink. 

Nearly 35 years into my own marriage, I know the kind of therapist I wouldn’t want to see if my relationship were in trouble: not someone who was neutral about whether my marriage endured or died, or who readily accepted my entitlement to have the best possible marriage. Instead, I’d want a therapist who’d be committed to helping us to cling together as a couple, warming each other against the cold of winter and seeking out whatever sunlight was still available while we wrestled with our pain and disillusionment. A good therapist, a brave therapist would be the last one in the room to give up on our marriage, not the first one. Such a therapist would be working from the knowledge that the next springtime in Minnesota would be all the more glorious for the winter that we’d endured together. 

Giuseppe, a married, seventy-five-year-old Italian, suffering from lung cancer and recurrent chest infections, caused his oncologist concern when he expressed a wish to die. He appeared very sad as he spoke of his limited future, his frustration at a considerably restricted exercise tolerance, and the boredom that set in at home.

He was the youngest of three children born to a farming family in Northern Italy, his education cut short by the onset of World War II when he was just fourteen. After serving in the army, Giuseppe traveled to France where he married and fathered two daughters. In the 1960s, the family migrated to Australia, where Giuseppe worked as a leading hand in the building industry until retirement a decade ago. He was proud of the respect he had earned for his contribution to the workplace, and especially of his family--"the very best!" He delighted in completing the crossword puzzle daily.

While volunteering an acceptance of his diagnosis, he described waves of sadness that came over him when he thought about his life ending. Yet when conversing more generally, he was interactive, spontaneous, could share a joke, and his mood was dearly reactive to the environmental context. His interest in sport and classical movies sustained his enjoyment of life. There was no hint of a clinical depression.

Acknowledging that his health was considerably compromised, he explained that he did not want to go on living with illness. He stated, "My chest is no good at all. I don't know about my future. I'm keen to get to heaven, not to go on with this chest. If I have to go, I don't mind. I accept whatever God wants for me."

He expressed this calmly, without evident distress or panic. The counselor acknowledged the normality of his grief, provided reassurance that he was not depressed, and explored how Giuseppe might take leave of his family. Until he died, the counselor high-lighted, there was a value to living.

The term "acceptance of dying" captures best the predominant mental state identifiable in Giuseppe. Although a "wish to die" fluctuates, there is no desperation about it, or search for a means to hasten his dying. Hoping that death ...
http://tinyurl.com/y93duweTips for Healthy Conjugal life
Marriage is a life time relationship foe every couple. Every couple wishes to lead a happy and peaceful life. The responsibility of such a relationship depends on both the alleys of marriage- the husband and the wife. This want does not depend upon age as every aged couple also wants to live together for the remaining part of their life. Therefore, it is the basic requirement for all the couples that want to live for a long life together with the same feeling of warmth in their relationship. As told earlier, both the husband and the wife are equally responsible for maintaining the love and warmth in their relationship. Both should try their level best to maintain the harmony in their relationship and at the same time they should not try to blame each other for any mishap or misfortune that comes to their life occasionally. As per the advice of many noted and reputed psychiatrists and social activists, both the alleys of married life should follow the points given below: Have faith in your spouse: Faith is the basic requirement for the success of a married life which binds both of them in the thread of love. The sanctity of this pious relationship depends upon their love and faith to a great extent. After the marriage, both the husband and the wife need to go out for different purposes or for join their duty, if both of them are working. In this situation they need to meet many people as well but in no situation they should make wrong or unfair assumption in their thought that, in the long run, hampers their relationship. Share your views open-mindedly: They should not hide even the slightest of doubts or misunderstandings in their mind. Whenever any thing new strikes their mind, they should feel free to make it clear open-mindedly. That encourages the transparency in their relationship and strengthens their bond. Respect the feelings of each other: This is a very important aspect of the relationship as both of them should respect the feelings of each other. They should feel confident about each other’s support in everything they do of think but it is also true and desirable that they should guide each other in the right direction if any one of them finds the other one wrong or misguided. Extend the helping hand when your spouse needs: That very aspect brings better understandings in the relationship of the husband and the wife. The husband needs to take care of the discomforts of his wife and should always try to be there whenever she needs your helping hand. Here it is advisable for the husbands not o make it an egoistic issue. If both of them maintain this aspect of the relationship, I have no doubt in the success in your relationship. Respect the sexual requirements of each other: Sex is undoubtedly an unavoidable requirement of the relationship and it is very true that the success of your relationship largely depends upon your sexual life. Looking at the intense requirement of sex, both of you should respect the sexual requirements of each other. The satisfaction in the sex satisfies both of you physically as well as emotionally. Respect the in-laws of each other: This aspect has very serious impact over the relationship of the husband and the wife. There are many instances available in the Indian society where the bond between them got severely damaged and the unfortunate divorce also occurred between them. Never let this happen in your relationship. Always be dutiful towards your in-laws and try to be respectful towards them. Try to manage everything skillfully even if you find them wrong. Develop a friendly yet respectful relationship with them so that they can also get the confidence in you and your attitude towards them. Never demoralize your spouse in the presence of others: This tendency hurts the ego of a person very severely. It can be very devastating for the self-confidence of the person. So be very careful of not demoralizing your spouse in the presence of others. Show your spouse that you care her feelings: This is very important to make your spouse that you really care each other’s feelings. Never show passiveness in your attitude towards your life partner. That will help you to build a good and healthy rapport between you two. These tips are very effective for maintaining the healthy relationship between the two alleys of wedding bond. If you wish to lead a happy, healthy and peaceful conjugal life, you can follow the tips listed here. Remember these tips are the advices of the successful couples who have lead their life successfully and peacefully. 


Illustration from Clyde Mendes column at  MetroSexual LA

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