Caring for the Physician in Couples Therapy

Day in and day out, psychiatrists-especially those involved with couples therapy-counsel and treat patients experiencing relationship problems with their spouses or partners. But what about the psychiatrist having a similar problem in his or her own life? Who does a doctor turn to for guidance and insight regarding such intimate matters?

Michael F. Myers, M.D., of Vancouver, British Columbia, asked himself this question about 20 years ago and now, three books and numerous doctor-patients later, he has a thriving couples therapy practice specializing in the healing of physician relationships.

In a recent interview with Psychiatric Times, Myers, who wrote Doctor's Marriages: A Look at the Problems and Their Solutions (Plenum Publishing, 1994), talked about the tremendous pressures physicians are faced with today. Foremost, said Myers, is how the decreased income caused by managed care and the changing work scene have altered lifestyles.

The Pressures

"Many men define themselves, not only by what they do, but also by how much money they make," said Myers, "and that outlook definitely holds true in the field of medicine.

"I'm struck by the number of times the male physician is actually quite worried by money, but hasn't identified it as such. He hasn't really explained to his wife that the reason why he's yelling so much or is so out of sorts is because he's really worried about finances. In other [nonphysician] couples I see, it's more overt; they're openly fighting about money."

Myers has also seen many physicians overwork themselves to maintain a standard of living that they had before by either working outside of managed care or working fee-for-service. "What this does, however, is make the physician less available at home, both as a husband or wife and as a parent to the children," he said.

On the opposite end of the spectrum, but still connected to money concerns, is the fact that some physicians are underutilized. "They're not getting as much work, so they don't have the option of working harder even if they could," Myers pointed out.

Unhealthy Competition

One unfortunate offshoot of the accumulation of pressure and the demoralization of the physician workforce is what Myers views as an unhealthy competition for jobs.

"I feel that in many areas there is less collegiality among physicians than there was 10 to 15 years ago," Myers explained. "Malpractice litigation continues to increase as well as licensure investigations of doctors. All of which creates a kind of internal angst in physicians, and affects how they communicate at home, how intimate their relationships are with their spouses or partners and, of course, their sexuality."

Another stress side effect Myers has noticed is an increase in mood disorders.

"This is all anecdotal, though," he said. "We don't have empirical research on the incidence or prevalence of mood disorders in doctors. There's some old data, but there's really nothing current.

"Many of my colleagues who work in the area of physician health tell me they are diagnosing more and more doctors with depression, and they're not exactly sure why that is, or what it means. For a while, when the SSRI [selective serotonin reuptake inhibitor] drugs came out, they thought that maybe it was because there are now cleaner drugs, like Prozac, and physicians are more open to embracing antidepressant treatment."

Myers said he also sees a number of doctors who self-medicate. "I get many phone calls that go like this, 'Hi, Dr. Myers, this is Dr. X calling. I've been feeling kind of depressed lately, so I put myself on Prozac about a month ago and I'm feeling a lot better now, but I don't want to self-medicate. Can I come in to see you?'"

Although Myers and his addiction medicine colleagues don't have recent empirical data on chemical dependency in doctors, they still see substance use disorders negatively impacting physician relationships.

"All of my addiction medicine colleagues say the same thing: that even though they don't have recent empirical data, the substance dependency numbers certainly don't seem to be dropping. In other words, we don't think that physicians' drug and alcohol use is lessening.

"I see many doctor-couples each year in which both are living with mood disorders; therefore, I've got them both on antidepressants. One could be bipolar, the other unipolar. Or one has depression, the other has chemical dependency. Let's face it, marriage is tough enough, and when you've got one or both partners living with these illnesses, it really wreaks havoc on your ability to work efficiently and effectively, to communicate well, to make love comfortably, to raise your kids...all kinds of things."

Myers notes that there is also a certain stigma attached to physicians living with depression or chemical dependency, so they delay going for help, or avoid it altogether. "Then," said Myers, "that gets into the whole area of stigma about going for some sort of marital therapy."

Myers said he has a whole group of physicians who come to him because they say it doesn't feel like they are going to a psychiatrist. "They tell me it feels like they're going to counseling, and that makes them feel 'less screwed up.'"

The Changes

Over the last 20 years, Myers has witnessed changes in the face of the medical workforce. "For one thing, there are more and more women in medicine," he explained. "The percentages of women enrolled in medical school are now pretty close to 45% to 50%. In addition, there are more minorities, international medical graduates, gay and lesbian couples and intercultural and interfaith marriages.

"Because of the cosmopolitan nature of where I live and work in Vancouver, it isn't unusual for me to look after doctor-couples in which one is Asian and the other is from the Indian subcontinent. Still another may be Canadian, the other from Thailand. And that details only interracial differences," he explained.

Myers said these groups bring their own texture to the two-couple therapist. "Most women doctors marry other professionals, many who are physicians themselves, but that's not always the case. I look after some women physicians and their husbands where they have a reverse traditional marriage. She has a much higher level of formal education than he has, and he works in a trade of some sort. Often when they are raising their kids, he is home full-time. It's pretty much like an old-fashioned or traditional male physician marriage."

He has also noticed more doctors coming to him who are in their second or third marriages.

"That could have something to do with physicians just getting older, but it could also represent that they have moved into these new relationships very quickly without resolving the immediate marriage, so their judgment may have been affected."

Myers said these physicians are usually interested in getting some couples work because they want to make sure their current marriage works.

"Many times doctors at first will say, 'I'm so busy, I really don't have time for couples therapy; I just want to live my life.' But then they'll read an article about high divorce in second or third marriages, and panic. Or they'll begin to see patterns in their present marriage that aren't unlike those in the previous ones."

With his younger physician couples, Myers notes that many are adult children of divorce, and openly admit they have some struggles with intimacy.

"It sometimes turns out that they're late in getting married because they develop an almost obsessive sense of 'This has to be perfect.' That's tough because they've put tremendous pressure on themselves. Or it sometimes works the other way around. Because of insecurity that developed through their parents' marriage and divorce, they have coupled very, very young, and are hanging on for dear life. Many times these marriages don't work because they're suffocating each other to death."

On a sad note, Myers said that as of 10 years ago, he had a certain number of physician couples in his caseload where one or both were living with HIV/AIDS. "With the exception of only one of those couples," Myers noted, "all have now died."

Doctor-to-Doctor

At home in Vancouver, Myers spends half his professional life in private couples' therapy practice, and the other half instructing physicians at a downtown teaching hospital.

When asked what he consistently tells his audiences, comprised mainly of psychiatrists, about counseling the doctor-patient in couples therapy, Myers said, "Make sure you treat your doctor-patient couple as a struggling couple first. See them as a couple who are having problems, both of whom just happen to be physicians. This is very important because if psychiatrists get blindsided by the fact that one or both of their patients are doctors, then sometimes they make assumptions that their problems aren't so bad, or that maybe they can take care of themselves.

"Doctor-patient [couples] need to be approached like any other ailing or struggling couple [that] comes to a psychiatrist. It's a very basic point, but I always like to remind psychiatrists of this, because I hear of so many situations where the physician-couple feels they didn't get the kind of care they thought they were going to get."