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The use of role and stress concepts in the assessment of marital conflict cases : the assessment of… Regehr, Henry 1962

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THE USE OF ROLE AMD STRESS CONCERTS IN THE ASSESSMENT OF MARITAL CONFLICT CASES The assessment of a sample of disturbed marriages i n terms of role and stress concepts.  by  HENRY REGEHR  Thesis Submitted in Partial Fulfilment of the Requirements for the Degree of MASTER OF SOCIAL WORK in the School of Social Work  Accepted as conforming to the standard required for the degree of Master of Social Work  School of Social Work  1962 The University of British Columbia  In presenting this thesis i n p a r t i a l fulfilment of the requirements for an advanced degree at the University of B r i t i s h Columbia, I agree thatjthe Library s h a l l make i t freely available for reference and study.  I further agree that permission  for extensive copying of this thesis for scholarly purposes may be granted by the Head of my Department or by his representatives. It i s understood that copying or publication of this thesis for f i n a n c i a l gain shall not be allowed without my written permission.  Department of The University of B r i t i s h ^Columbia, Vancouver S,^-Ganada. Date  S4/^/ /0.  /ffj?.  iii.  ABSTRACT  The Council on Social Work Education published, i r u l ^ . study on the objectives of social work education. This thirteen-volume work proposed, in the section on casework method, that the concepts of "role" and "stress" be used i n combination for the purpose of assessing clients' problems. Some research has already been done to bring the theory to the level of practice, but i t i s gener a l l y agreed that further testing i s s t i l l necessary. This thesis i s an attempt to make a contribution i n this area by applying "role" and "stress" concepts to a sample of social work practice. Specifically, the objective i s to test the usefulness of these formulations in the assessment of marital interaction. 0  a  The sample group are eight cases from the f i l e s of the Adult Clinic, Mental Health Centre. Adults there are seen on referral from medical practitioners for the primary purpose of assessment and treatment of psychiatric problems, but relatives are seen where this i s deemed necessary by the treatment "team". Frequently the spouse of the patient i s drawn into the treatment program and marriage counseling i s done when the problem in the marriage is considered to play a s i g n i f i cant part in the etiology of the psychiatric symptoms. In this study, the reciprocal relationship of husbands and wives seen in the Clinic were examined and the case records were analyzed on the basis of the concept of"stress". The attempt was made to identify (a) the source of stress, (b) the values threatened, (c) the duration of stress, (d) the response to stress, (e) the effect of the stress on the reciprocal role relationship of husband and wife. Assessment and re-definition of the marital problem was then attempted in each case. The study brought a number of analytical features to light, (a) The use of the concept of reciprocal role functioning in a marriage made i t possible to partialize the clients' total social functioning and extract the manageable units of husband and wife roles, (b) The use of stress concepts revealed a pattern of stress and response to stress that began in the early experiences of childhood and extended into the marriage relationship, (c) There was a discernable relationship between the source of stress and the development of conflict i n the marriage, (d) The nature of the stress factors appeared to color the quality of the interaction between the marriage partners, (e) There appeared to be a progressive building up of stress factors in a discernable pattern. This has been only a beginning attempt at testing out the usefulness of these concepts and i t would seem that further research i s indicated.  ACKMOv'JLEDGEiyiENTS  My warm thanks are due to Dr. Charles McCann of the School of Social Work, for his kind assistance i n the preparation of this thesis; to Dr. Leonard Marsh of the School of Social Work, for his help i n the beginning phases of this work; to my colleagues at the Mental Health Centre for their encouragement and helpful suggestions. The extent of my indebtedness to my wife, L i l l i a n , only I can f u l l y appreciate.  TABLE OF CONTENTS Chapter I  page  Role and Stress Theory - An Introduction  A preliminary statement of the problem. Role theory in the social sciences. Attempts to relate the theory to social work practice. Need for research. General outline of social role theory and i t s components. Outline and components of stress theory. Meaning of "problem". Purpose, setting and scope of this study Chapter U  A Proposed Framework for Assessing- Marital Interaction i n Terms of Stress Concepts  The scope of this analysis. Methodology for application of concept of stress by components and categories. The criteria used for the selection of cases. Some special.problems presented by the case recordings Chapter III  14  21  Implications of this Study for the Assessment of Marital Conflict  Restatement of the purpose of the study. Limitations of the study. Outline of the major findings of the study. Evaluation of the usefulness of role and stress concepts for assessment of marital conflict cases. Some further areas needing research. Implications of the findings for casework assessment Appendices: A. B. C.  .«  Application of the Concepts of Stress to Assessment of Marital Relationships  Introductory comments about the cases. Statistical information about the marital partners. Presentation: case summary; schedules depicting sources of stress, values threatened, duration of stress, responses to stress, effect of stress on the reciprocal role relationship of husband and wife; . assessment in terms of stress concepts Chapter IV  1  Psychiatrist's Assessment Note (sample - Case A) Social Work Assessment Note (sample - Case A) Bibliography  74  i i .  TABLE OF CONTENTS ( c o n t i n u e d ) page SCHEDULES AND CHARTS I N THE TEXT  (a) Schedules A^, Ag Bi,  B  ±  D  l f  37  2  42  2  48  E , Ez ±  •••••••••••.•««••••..••»••••••••«•»••••••••••••••••••••«••»•«»  t  H  1 }  27  32  2  C, C D  ••••«.••»«••••••••«»..«•••.••••••«»».•..».>.>>.>.•......>»•»..  62 68  Eg  (b) C h a r t s C h a r t 1.  S t a t i s t i c a l I n f o r m a t i o n About t h e M a r i t a l P a r t n e r s i n Cases P r e s e n t e d i n t h i s Study  24  THE USE OF ROLE AND STRESS CONCEPTS IN THE ASSESSMENT OF MARITAL CONFLICT CASES  CHAPTER I ROLE AND STRESS THEORY - AN BJTRODUCTIQN  The Problem With the development of any new theory in the f i e l d of the social sciences, particularly psychology and sociology, there must come a period of research and testing before i t can be accepted as a useful concept for understanding human behavior,  But  a  further step of research and testing must be  carried out to make i t useful to the treatment disciplines for assessing and treating individuals or groups who show signs of malfunctioning.  The theories  of social role and of stress are no exception. The purpose of this study i s to assess marital interaction of patients referred for psychiatric treatment, utilizing the concepts of role and stress. The f i r s t chapter w i l l review pertinent theoretical material; chapters two and three w i l l describe the application of the theory to specific case records, and chapter four w i l l discuss some of the findings of the study and the implications of these for social work practice. Social psychology has studied group dynamics, using the group member roles as units for analysis.  Sociology has studied broader social phenomena,  using the institutionalized role as one means of analysis.  The treatment dis-  ciplines, and particularly social workers, have adapted these concepts to their particular area of interest - assessment of individual malfunctioning, and treatment of people who show such symptoms. Social workers have been much concerned in recent years with attempts to relate role and stress theory to their discipline, and some noteworthy efforts  - 2 -  could be mentioned. Boehm has attempted to enunciate the key principles of social role and stress theory as related to the education of social workers. 2 Bernard discusses role and stress concepts from the broad sociological base of  3 national social problems. Perlman relates role theory to principles of casek work. In recent years, attempts have been made increasingly to apply the theory to actual casework practice, although this i s s t i l l at such an early stage that 5 many of the concepts of role and stress are s t i l l without validation.  Conse-  quently there i s a real need at the moment to test out the concepts of role theory i n a l l areas of social work practice, both in assessment of clients and in the treatment process.  Specifically, research and testing of the theory i s  required i n i t s application to the assessment of marriage relationships, and this thesis i s one attempt to do this. The specific focus of the study w i l l be outlined later i n this paper.  Boehm, Werner W., Spc^a.! Casework. Method in Social Wprk; E d i t i o n * (Vol. X, Social Work Curriculum Study), Council of Social Work Education, New York, 1959. 2 Bernard, Jessie, Social Problems at Mid-Century. Dryden Press, 1957.  3 Perlman, Helen, "Intake and Some Role Considerations," Social Casework. Vol. XLI, No. 4, April, I960. Maas includes, i n his discussion of the meaning of the term "casework", a definition by Swithen Bowers: "Social casework is an art i n which knowledge of the science of human relations and s k i l l in relationships are used to mobilize capacities in the individual and resources i n the community appropriate for better adjustment between the client and a l l or any part of his total environment." (Maas, Henry S., "Social Casework", in Concepts and Methods of Social Work, edited by Walter A. Friedlander, Prentice-Hall, second edition, 1959, P. 19.)  5  See: Olds, Victoria, "Role Theory and Casework, A Review of the Literature," Social Casework. Vol. XLHI, No. 1, January, 1962.  -3 Role .Theory - Its Content Before going into a discussion of the application of role and stress theories, i t w i l l be necessary to describe i n some detail the actual content of these formulations. At the present stage of development of role, theory, there i s a great divergence of opinion among i t s exponents as to a definition of "role".  This  i s shown very clearly i n Olds' review of recent literature on the subject.^" Some writers hold, she says, that roles are seen only i n the reciprocal interaction between persons when their actions are organized by the expectations of each person i n the reciprocal relationship and by society i n general.  Bert  Kaplan, another theorist, Olds says, holds that role i s "the mediator between 2 societal requirements and individual behavior."  A review of the literature  also shows that theorists see each individual contributing to the role he plays, in that each person has his own unique ego functioning. In turn, the role exerts a formative influence on the person himself because the role assigned to him w i l l require that he add new characteristics i n order to f i l l the role more adequately. Bernard introduces two further concepts: institutionalized roles.  group-related roles and  She sees three specific functions that must be per-  formed i n any successful action group:  ( l ) ideas must be furnished; (2) inter-  personal relationships must be maintained on a friendly basis so that members w i l l be co-operative; and (3) there must be leadership.  She sees institutiona-  lized roles.as the "prescribed or specific integration of behavior patterns  Olds, op. c i t . , p. 1. Ibid., p. 4. Bernard, oo. c i t . . p. 41.  - 4 -  embodied in law,.custom, tradition, convention, or other norms which t e l l s how certain functions are to be performed."^  Here the unit of organization i s not  the person performing the job, but the function being performed, as husband, wife, teacher, and so. on.  From even this cursory look at the literature, i t  w i l l be apparent that i t is most d i f f i c u l t to arrive at a concise definition of "role" at this early stage of analysis and research.  Possibly an acceptable  description, however, i s one given by Perlman as i t includes a number of the concepts proposed by various theorists. he says that role i s s  ... a person's organized pattern or modes of behaving, fashioned by the status or functions he carries in relation to one or more persons. Such a behavior pattern i s selected, shaped and colored by several dynamic factors: ( l ) the person's needs and drives what he wants, consciously or unconsciously; (2) the person's ideas of the mutual obligations and expectations that have been invested (by custom, tradition, convention) in the particular status and functions he undertakes; (3) the compatibility or conf l i c t between the person's conceptions of obligations and expectations and those held by the other person(s) with whom he is i n rec iprocat ion• It w i l l be useful to briefly discuss some of the principle concepts included in this statement as i t w i l l be used as the frame of reference in this thesis. The concept of role implies a relationship between persons in the context of their respective status and functions.  No role exists in isolation,  but must be patterned to gear in with another role that i s complementary to i t . For any role being performed, there must be a role partner, or to use John P. Spiegel's term, an "alter". Boehn speaks of this relationship as "reciprocity" and adds that the  * Bernard, oo. c i t . . p. 42. 2 ^  3  Perlman,- OP. c i t . , p.  Spiegel, P., "The Resolution of Role Conflict within the Family", A Modern Introduction to the Family, edited by N. W. Bell and E. F. Vogel, Free Press, I960, p. 363.  - 5 -  degree of c l a r i t y i n the definition of the role affects the clarity i n the definition of the reciprocal role.*  The concept of role also implies that  there i s goal-oriented "organized pattern" i n the interaction of persons in' reciprocal roles.  I t i s the task of the caseworker to discover this pattern,  thus making i t possible to predict with some degree of accuracy how the client w i l l perform i n any given role.  But the goal toward which this activity i s  directed w i l l be determined by the three "dynamic factors" which Perlman mentions:  ( l ) the person's individual needs and drives; ( 2 ) the person's cul-  turally .determined (defined) idea of mutual obligations; and (3) the compatib i l i t y or conflict of mutual obligations and expectations between the persons in reciprocation - or between the ego and the alter. The person's individual needs and drives, physical and psychic, provide the material from which he makes his own unique contribution to the roles he performs.  Physical endowment, body chemistry, presence or absence of d i -  sease affect his role performance.  Intrapsychic activity between the i d with  i t s primitive drives and super-ego with i t s controls on these drives, as well as the ego's mediating activity between the i d and super-ego, affect the person's performance i n roles.  The culturally defined mutual obligations and ex-  pectations of persons i n reciprocal roles are of particular concern to the social worker in the process of making an assessment of his clients as they form the framework for reciprocity.  Bernard's concept of "institutionalized roles"  i s particularly useful i n understanding the cultural component in forming ideas of mutual obligations:  Boehn, O P . c i t . . p. 99.  - 6-  An institutionalized role ... i s a prescribed or specified integration of behavior patterns embodied i n law, custom, tradition, convention, or other norm which t e l l s how certain functions are to be performed. Illustrations of the institutionalized roles are: wife, mother, husband, father, teacher, pupil, physician, patient ... and so on .... Not the individual who performs the ^ job, but the function to be performed i a the unit of organization. Performance of role, then, i s learned by the persons who wish to occupy them, and this i s done by accepting the standards which the culture lays down for any specific role.  By the same token, a person expects his  alter to conform to the cultural standard l a i d down for that role.  By way of  illustration, a man w i l l learn his behavior pattern for the husband role in the culture or subculture in which he i s raised, while at the same time expecting his wife to perform i n her role i n the way that his culture or subculture has taught him a wife should perform. Perlman's third dynamic factor influencing a person's role performance i s "the compatibility or conflict between the person's conceptions and expectations and those held by other person(s) with whom he i s i n reciprocation." There has been a great deal of attention paid by social scientists specifically to the complementary role expectations of husband and wives and we may use Spiegel's work as an illustration: ... an American middle-class wife tends to expect her husband to treat her as an equal. She expects of her husband a good deal of independence, i n i t i a t i v e , and planning for future success i n his occupation, but i n his relations with her and the children, she expects co-operation, sharing of responsibility, and individual consideration. Reciprocally, the husband expects his wife to help in his plans for future economic and social success, notably by putting his success goals above any personal career or occupational goals of her own, and by developing the social and domestic s k i l l s  Bernard, op. c i t . . p. 42.  - 7 suitable to his particular occupational status. For satisfying reciprocation to take place, then, there must be a willingness on the part of the persons i n complementary roles to accept some common frame of"reference for"interaction.  Where this does not take place,  conflict and role impairment ensue. Role Impairment;  This i s an important concept i n the analysis of  problems i n terms of role theory. McCann discusses i t i n these terms: Role impairment provides that d i f f i c u l t i e s i n social functioning arise when the person i s unable to perceive the expectations of a role accurately and/or i s unable to perform i n line with the expectations due to physical, emotional or social handicaps. Since the role structure of society i s constantly changing and varies from social class to class, group to group and individual to individual, i t i s necessary to determine how any given person defines his role in a relationship.  The Concept of Stress Any person performing i n his various roles comes into conflict in the performance of those roles.  For this reason the concept of stress has been  used along with the concept of social role as a basis for assessing problems of social functioning.  Stress, says Bernard, i s "the situation which involves 3  threat to functioning i n any one or more roles." three components:  She breaks this down into  (l) the stress factor which threatens the person performing  the role; (2) the value, held by the person, which i s threatened by this stress factor; and (3) the reaction of the person to the threat. Boehm adds to this: ... stress factors may originate i n either realm of' the interactional f i e l d , social or individual; ... they may not be consciously perceived, 1  2  Spiegel, O P . c i t . . p. 363..  McCann, Charles W., "Role Theory and Professional Responsibility," Social Worker. Journal of C. A. S. W., Vol. 29. No. 3, June, I96I. 3 Bernard, O P . c i t . . p. 70.  - 8 -  but manifested i n the individual's response to.them and, therefore, detected only through changes in the role performance. Responses to stress factors vary from individual to individual and, depending on the threshold of tolerance, i.e., his somatic and ego capacity, the nature, intensity, and scope of stress, and the vulnerability of the factor affected by stress. Stress may affect the orchestration of the social and personal elements of which the client's role performance i s an expression. Boehm then expands on Bernard's formulations regarding stress and the discussion which follows here i s based on his material. Stress Factors,:  these are threats which may have their origin i n the  person's own physical or psychological make-up, i n his physical environment, or in his social system.  These personal threats may be such factors as i l l  health or the possibility of death. Threats from the external environment may be the possibility of unemployment, nuclear attack or accidents; they may be anticipated changes or new- situations which create problems of adaptations, such as marriage; they may be problems i n socialization where an individual with limited endowments i s forced into roles by society i n which the person sees himself unable to function.  These stress factors w i l l produce impairment  in one or more of a person's roles, and this impairment, in turn, may become an additional source of stress. Value Threatened: , an external or internal situation becomes a stress factor only when some value which a person holds i s threatened.  Such values  may be health, l i f e , possession of property, religious or p o l i t i c a l freedom, financial security, self-respect, and so on.  These values may be related to  one's self, one's loved ones, or one's group, but their meaning to the person involved i s what gives them significance for him. Reaction to, Stress:  Boehm, jap,., ,QJt*> P« 107  this involves reaction responses which an  - 9 individual makes. The goal of this response is to maintain the level of social functioning or the performance of roles, which existed before the stress factor threatened the values held by the person.  We must keep in mind, of course,  that much of human behavior consists of handling threats successfully, and the degree of stress reaction w i l l depend on the intensity of the stress, the degree of Importance the value threatened holds for the person, and the personal ability of the individual to deal with the threat. The reaction to the stress, then, may be a healthy adaptation to a new situation.  I t i s only when there i s an  inability to deal with the stress, or there i s a maladaptation i n the form of an unhealthy use of defense mechanisms, that a real problem arises.  In the  treatment professions, there i s concern with those stress situations which create such problems for people. Jessie Bernard sees two areas i n which stress reactions take place: on an individual level and on social or role performance level. Individual: or emotional.  reaction to stress on this level can be physiological  Although stress reactions are possible i n any physiological sys-  tem, they usually are glandular in nature.  Paralleling the physiological reac-  tions and often part of them, are the emotional reactions of fear and anxiety. In a sense, this anxiety i s the central core of any stress situation because i t i s here that the nature and intensity of the stress, as the person sees i t , finds subjective expression. The pathological use of defense mechanisms, of course, may form protective coverings over this anxiety and, failing this, ment a l illness may result.  But the core problem i s s t i l l the anxiety.  Role-related Stress Reactions:  on this social or interpersonal level,  response to threat may take the form of aggression, withdrawal, hostility, apathy, escape, and so on. Where this occurs, role impairment, or a breakdown in role  - 10 -  performance, takes place.  The nature of "role impairment" has been discussed  earlier. In the light of these considerations on stress, we might use Boehm's system of theoretical propositions or hypotheses:*" 1.  Stress i s an inevitable aspect of l i f e ,  2.  The source of stress can be internal, due to somatic or psycho-  logical factors, or external, due to environmental factors (physical and.soclocultural) and there can be a combination of a l l of these, 3. Regardless of i t s point of impact, stress may affect the functioning of the personality i n any of i t s aspects, physical, emotional, mental, spiritual, social, and may manifest i t s e l f through lowered performance i n one or several social roles, 4.  Because of the reciprocity of role behavior and the inter-  relatedness of roles, role performance d i f f i c u l t i e s may themselves constitute a source of stress which may further reduce performance in the roles so affected and may affect the performance of other roles, 5.  Prolonged stress in one area, or stress affecting several areas  of functioning (several roles) can lead to extended role breakdown and, i n turn, to personality disorganization.  However, the occurrence of stress i t -  self does not automatically lead to dysfunction. 6.  Man tends to absorb stress situations through various types of  defensive and adaptive responses i n an effort to maintain or re-establish a dynamic equalibrium which expresses i t s e l f in a certain level and mode of social functioning. 7.  The major forms of adaptation are flight and fight and can take  place in the physical, psychological, or social realms or in a combination of  Boehm, op.  cit..  p. 109.  - 11 -  these. 8.  The physical, psychological, or combined responses available to  the individual may not be adequate to cope with stress and, therefore, social intervention from outside to assist the client i n his struggle for adaptation to stress may be necessary. 9.  Resources outside the individual which are mobilized to combat  the effects of stress and to assist the individual i n his struggle for adaptation take the form of role support. This support may be given by professionals or by family and friends. The Concept of Problem;  Following Boehm's terms, "problem i s defined  as a person's response to stress situations which affects his role performance in such a way as to result in role impairment."* Problems, then, result from the stress situations and affect adversely the individual's social functioning.  This i s expressed i n his mal-performance  of the roles i n which he finds himself.  This mal-functioning may be perceived  by the individual and this may or may not induce him to seek help.  I t may be  perceived by the society i n which he moves and, depending on the degree of the role impairment and i t s effect on the environment, society may or may not intervene.  Society has also provided help i n problem-solving i n keeping with i t s hu-  manitarian standards and the degree to which i t sees a responsibility for meeting the needs of people with problems i n social functioning.  The helping profes-  sions, In keeping with society's prevailing humanitarian values, are concerned with controlling, removing or reducing stress.  Casework, as one of these profes-  sions, deals with, as Boehm calls them, certain core problems and i t s main areas  1  Boehm, op. c i t . , p. 111.  - 12 -  of operation try to meet these problems. Boehm are:  The areas of operation defined by  child welfare, family welfare, medical social work, psychiatric  social work, school social work.* Family welfare deals with the problem of inadequate performance of interrelated roles of the members of the family in the family interaction. Marriage counseling, then, would deal with inadequate reciprocal role functioning of marriage partners.  The Particular Focus of this Study This study, being exploratory, i s concerned particularly with attempting to apply the social role theory and stress theory concepts to the casework assessment of marital interaction i n patients referred for psychiatric treatment. Because of the relative newness of this theoretical framework and because i t i s highly abstract, experimentation i s necessary before i t s real value can be determined.  This i s one attempt in that direction.  The setting for this study i s the Adult Clinic, Mental Health Centre. Although this i s not primarily a family and marriage counseling c l i n i c , but a c l i n i c for the treatment of adults suffering from mental illness, there i s s t i l l a considerable amount of marriage counseling done. Clinic procedures allow family members, who have a significant role to play in relation to the patient, to be seen as i s deemed necessary during the course of treatment of the patient. This allows spouses of patients to be seen on a marriage counseling basis when the marriage i t s e l f has played a significant part in the etiology of the patient's  1  Boehm, O P . c i t . . p. 112.  - 13 -  illness.  Joint interviewing i s also done when this seems indicated.  i s operated by the Provincial Mental Health Services and, u n t i l now,  The Clinic has been  the only out-patient and day hospital c l i n i c operated by the Provincial Service. It i s a multi-disciplined setting where psychiatrists, psychologists, social workers and nurses work together in treatment "teams'.^ 1  -  The admission procedure at the Clinic requires that the patient be interviewed by a psychiatrist, and, i f possible, that a relative be seen by a social worker for the purpose of making a social assessment. Sometimes the patient i s also seen by a psychologist for psychometric testing.  Following  this, the team meets for an Intake Conference where a diagnosis i s made and a plan for action i s decided on.  On the basis of the conference decision, the  patient i s either referred back to his family physician or i s taken into treatment", by a member of the team. For this study, we w i l l be using cases which have been taken into treatment by psychiatric social workers. Because this preliminary investigation is necessarily brief, we w i l l be using, for the purpose of this study, the information-recorded  at the time  of assessment, as well as the recording from the f i r s t five treatment interviews. Although there is no intrinsic value in the number "five", i t is f e l t that much information necessary for a more complete assessment w i l l be coming out of the f i r s t few interviews. Let us now go on to relate role theory to assessment of marital interaction.  A team i s a group of the professionals mentioned who work together under psychiatric .direction to .treat each patient as they determine most suitable.  CHAPTER I I A PROPOSED FRAMEWORK FOR ASSESSING MARITAL INTERACTION IN TERMS OF STRESS CONCEPTS  It was stated earlier that the concepts of role and stress theory are s t i l l i n very early stages of development and that many are s t i l l without validation through testing.  The.following chapters describe a beginning  attempt to assess the usefulness of the concepts as a tool for gaining a better understanding i n one area of social casework. Specifically, we would like to discover, i n a beginning way, whether the theoretical formulation can be helpful for gaining a better understanding of the dynamics of disturbed marriages. In studying disturbed marriage relationships, we are limiting the role theory concepts to those dealing with reciprocal relationships and to impairment i n the specific roles involved i n those relationships; that i s , i n the husband and wife roles.  What we shall be concerning ourselves with then, 1  are the concepts of stress as laid out i n the Curriculum Study, relating these to the reciprocal role relationships of husband and wife.  The approach w i l l  be to analyse case records i n the following stress concept terms:  the source  of stress, the value threatened by the stress, the duration of the stress, the individual response to stress and finally the effect of this stress and response to stress on the marriage relationships. This chapter w i l l deal with the approach used for this study.  Boehm, W., Curriculum Studies. Vol. X.  - 15 -  The Concept of Stress In chapter one of this paper, Boehm's analysis of "stress" was outlined under the following headings:  the source of stress, the value threatened  and the response to stress. Boehm states, as noted previously, that "stress factors are threats that arise within the individual's body, his physical environment, the function 1 of the social system, and within the individual's network of roles".  Because  we are here concerned with the reciprocal marriage roles, we w i l l highlight, i n this study, mostly the sources of stress coming from "xtfithin the individual's network of roles".  Other sources of stress w i l l be included only as they affect  directly the marriage relationship. Regarding the "value threatened" i t w i l l be noticed that each person discussed here has a value system differing from the others in keeping with his own unique cultural background.  Boehm, thus, suggests that "the subjective  meaning which the value holds for the individual concerned needs to be examined in addition to the objective value i t s e l f since different people may attach d i f 2 ferent importance to the same value".  In the cases presented, this w i l l be  seen in many ways, but particularly in the meaning the various people put on dependence and independence. to maintain the relationship.  Some of the clients are very dependent and wish Several have strong dependency needs but react  negatively toward becoming dependent on their particular spouse. the spouse's dependency, others react violently to this.  Some accept  Each client must there-  fore be seen i n his own right and with his own unique value system. Boehm, O P . c i t . . p. 107. LQCi c j t .  - 16 -  Similarly-, "response to stress" varies from person to person. Each client discussed in the following cases had his own unique and habitual response to stress - a response frequently developed i n early childhood.  This i s  seen quite clearly where sufficient material on the client's early history was available i n the records.  This w i l l be discussed more f u l l y in the fourth chap-  ter of this paper. Two other factors are added to this analysis for the purpose of the present study:  the "duration of the stress" and the "effect of the stress and  the person's response to stress on the reciprocal relationship of husband and wife". The "duration of stress" i s included here i n order to provide some form of a time sequence i n the development of stress within the client. I t also provides a clue to the extent to which responses have become ingrained and habituated. The effect on reciprocal relationship of husband and wife i s the most significant factor for the purpose of this study since we are attempting to relate stress concepts to the assessment of disturbed marriages.  Deprivation of Early Childhood Meeds as a Source of Stress There may be some question about including early l i f e experiences as sources of stress which affected, eventually, the marriage relationship.  They  were included because of the writer's psychodynamic orientation and because such experiences as loss of parental love, failure in provision of an ego ideal, and rejection could be seen as stress factors, as Boehm puts i t , "within the individual's role network".'*'  Boehm includes i n this lack of stability and security  Boehm, oo. c i t . . p. 107  - 1? in habitual social roles, threats to existing relationships, and role confusion, a l l of which are experiences the child can suffer. When responses to these early experiences become habitual, lasting throughout l i f e , i t i s possible that they may affect interpersonal relationships in which a person becomes involved.  Where the response has been an un-  satisfactory one and this becomes habituated, then i t might also be possible that i t w i l l affect future interpersonal relationships negatively, particularly the very close relationship i n marriage.  I t was therefore considered necessary  to include i n this study stresses i n the early l i f e experience and the habitual response to this stress, i n order to discover whether some relationship between these and marital conflict did exist,  selection of c s^a a  It was explained earlier that the cases used in this study were taken from the Adult Clinic, Mental Health Centre, f i l e s .  I t was also mentioned that  the function of the Clinic was not primarily to provide a marriage counseling service but that this service was provided where a marriage problem was an i n tegral part of the total problem for which the patient was referred to the Clinic.  The fact that the principle function of the Clinic i s to provide psy-  chiatric treatment and i s not a marriage counseling agency, immediately circumscribes this present study.  The case records to be analysed here do not deal  simply with marriage partners who were i n conflict with each other, but w i l l deal with marital conflict i n cases where one partner was referred to the Clinic for psychiatric treatment. It may be that this study w i l l indicate that there i s , i n fact, some relationship between mental illness, or personality functioning as a whole, and  - 18 -  marital conflict,  but this i s not the focus of this study.  We shall be looking  only at the marital conflict and the factors which brought about this conflict. It was found, on investigation of Clinic f i l e s , that various approaches were used i n dealing with such marriage counseling cases.  In some cases, only  one partner was seen by a therapist. In some cases, a psychiatrist saw one partner i n treatment interviews and a caseworker saw the spouse.  Sometimes a case-  worker saw the patient in treatment over a long period and the spouse was seen only a few times.  The f i r s t step, therefore, was to devise a set of criteria  that would help to select cases most suitable for assessment here.  The following  criteria were developed: 1.  Both marriage partners were to have been involved in the treatment  process i n order to ensure that information regarding both would be available. 2.  Both partners were to have been seen i n at least five interviews  beyond the original assessment.  This was included because significant diagnostic  information would be coming out of at least that many .interviews. 3.  T  he five interviews beyond the original assessment were to have  been held by caseworkers.  This criterion was included because the present study  deals with casework assessment. 4.  The major focus of the assessment and treatment processes during  these interviews, was to have been the marriage interaction.  Betty Morton, in her M. S. W. thesis, "The Psychodynamics and Treatment of the Male Partner in Marital Conflict Cases," (U. B. C. School of Social Work, 1957)i states the following i n regard to "marital conflict": "In a broad sense ... a l l cases are usually categorized as marital conflict cases when either of the marriage partners asks for help on the basis that their marriage i s unsatisfying. While the patterns of expressing marital discord are legion, Dr. Nathan W. Ackerman points out that disturbances of the marriage relationship are characterized by two salient elements: (a) failure of reciprocity of satisfactions, and (b) conflict; the conflict bearing, usually, a specific relationship to the failure of reciprocity in the relationship."  - 19 The use of these criteria posed a serious d i f f i c u l t y in selecting *  cases from the Adult Clinic f i l e s .  There were not'enough cases that met these  criteria available to use sampling techniques. As i t turned out, eight cases did apply and a l l cases were used in this study.  The implication i s that the  cases presented here are not necessarily a representative sample of marital conf l i c t cases referred to the Clinic.  Actually there were many cases i n the  Clinic f i l e s in which a marital conflict was described as a part of the problem, but because of variations i n assessment and treatment procedures demanded by the nature of each problem, the specific information required for this study was not available in the records. The absence of adequate sampling w i l l have to be seen as one of the limitations of this study.  Differences i n the Handling of Cases i n the Clinic Although there are standard intake procedures i n the Adult Clinic, the method adopted beyond this, as already mentioned, varies with the nature of each particular situation.  Thus the cases used here do not f a l l into a neat pattern.  In some cases the patient who had been referred for treatment was seen by a psychiatrist for several interviews before being referred to the caseworker for continuing treatment.  Also the spouse, seen o f f i c i a l l y as the "relative of the  patient" was not necessarily drawn into casework treatment immediately following assessment.  In "Case B", for example, the wife was admitted as the patient, but  the husband was not drawn into treatment until after some ten interviews had been held xd.th the wife.  This probably meant that the focus of the interviews was  more treatment oriented and the type of information required for the present study was not as fully obtained as i n other cases. the accuracy of the findings of this study.  This again xAll reflect on  - 20 -  In a l l cases, however, the f i r s t five interviews held with a social worker beyond the o f f i c i a l assessment were used for the purposes of this paper.  The Case Recording Several difficulties also arose from the way in which the cases were presented in the recordings. First, because an individual was referred to the Clinic rather than married couples, i t was usually this individual xtfho was given a more thorough examination regarding early history and present functioning. It was also this individual who was admitted as a patient. The spouse was seen as a "relative".  Consequently more information was available about the one partner  than about the other. I t was, therefore, easier to see a developmental process of stress factors discernable in the person regarded as the patient. An exception to this was "Case D" where the wife was seen f i r s t as a patient, but because of the nature of the marital problem, the husband was admitted as a patient in his ovm right and given a regular assessment.  Here more  complete information about the husband was available for analysis in this study. Secondly, the cases were not written up i n terms of the concepts of stress as laid down in the Curriculum Study. In some cases, the material classified under "source of stress", "value threatened", "duration of stress" and "response to stress" could be identified in the records f a i r l y clearly. However, in some cases, a more subjective judgment had to be made by the writer from the recorded notes.  This was particularly true i n the case of the "effect on  reciprocal relationship of husband and wife". Material for this category was interwoven into the record and had to be gleaned out by the present writer and rewritten into terms useful for this presentation. This subjective element no doubt w i l l influence the accuracy of the findings and this, again, w i l l have to be recognized as one of the limitations of this study.  CHAPTER U T APPLICATION OF THE CONCEPTS OF STRESS TO ASSESSMENT OF MARITAL RELATIONSHIPS  In this chapter we shall present the application of the concepts of stress to the assessment of specific cases from the f i l e s of the Adult Clinic. Mental Health Centre.  These cases a l l involve a marital conflict and the eight  cases selected meet the c r i t e r i a laid down i n the previous chapter. The case material i s analysed in terms of stress concepts and the assessment of the marriage i s then written out i n these terms. By way of introduction to the case presentations, i t may be helpful to make some observations about the eight cases selected. First i t i s important to note that in every case: the referral to the Clinic was made on psychiatric grounds; that i s , one of the partners was showing behaviour characteristically representing some form of psychiatric i l l ness.  I t is important to notice that the present assessment' takes note of these  symptoms only as a source of stress i n the marriage or as a response to stress. We are here concerned not with the diagnosis of mental illness but with the relation between the client's behaviour, whatever the psychiatric diagnosis, and the interaction of the marriage partners. In a l l of the eight cases except one, the wife was referred to the Clinic by the doctor for treatment.  Only in-the one case ("Case G") was the  husband referred but this had been only with the wife's insistence that he seek help because she had herself received treatment at the Clinic some years before.  - 22 -  In six cases the wife in the marriage was admitted for treatment and seen as the patient while the husband was seen as a "relative of the patient". In "Case G", as already mentioned, the husband was admitted as the patient and the wife was seen as "relative of the patient".  In "Case D" both husband and  wife were admitted for treatment, each i n his own right.  However, marriage  counseling was carried on i n this case as in the other cases. In six cases there had been no previous marriages by either of the partners.  In "Case D" the wife had been divorced once and in "Case G" the wife  had been married before. A chart listing the ages, occupations, length of the present marriage, number of times each person was married previously, and each partner's religious a f f i l i a t i o n precedes the presentation of case material. In a l l cases, the husband and wife were living together.  Presentation of Cases Each case i s analysed separately i n this study. First in each case presentation i s a detailed exposition for each of the marriage partners of the stress factors, the values threatened, the duration of the stress, the response to stress and the effect of the stress on the marriage inter-relationship. Here we w i l l be following Boehm* s formulation of the "concept of stress" as outlined in the Curriculum Study. Volume X.  Wherever sufficient material about the early  l i f e of either one of the marriage partners was given to show that childhood experiences were stress factors affecting later behaviour i n the marriage, this was included.  Other than this, we have sought to include only stress factors  which directly related to the marriage interaction. related directly to the purpose of this study:  The reason for this i s  to use the "concepts of stress"  - 23 -  as a means of assessing marital interaction i n marriage conflict cases. Folloxtfing the charts describing each partner's behaviour in terms of stress concepts i s an assessment using the outline developed i n the chart, but adding for illustrative purposes material presented in the assessment notes by the psychiatrist and by the social worker. Added to this, material related to assessment i s also taken from the f i r s t five treatment interviews with both husband and wife by one or two social workers. It was f e l t that a case summary preceding each analysis would be helpf u l to form a basis for presenting the analysis.  The material i s taken directly  from the case records of the social workers' and psychiatrists' reports. The latter w i l l explain some of the psychiatric terms that appear in the summary. In the summary, these psychiatric terms w i l l be accepted as part of the nomenclature of the particular agency in which this study was done. Because the psychiatric terms have varying meanings to different professionals i n the f i e l d , no attempt w i l l be made to define these other than presenting them i n the context in which they were used.  They w i l l , however, be defined where they are used i n  the analysis of the cases. The case material i s now presented in the following pages.  Chart 1. - Statistical Information About the Marital Partners in Cases Presented i n this Study Cases A  B  Age of Husband  37  32  Age of Wife  31  37  .  C  D  E  F  G  H  ¥f  51  39  39  43  43  31  41  29  39  47  48  Accountant  Carpenter  tfillworker  Salesman  Occupation of Husband  Regional Dept. Manager i n Sales Electrician chain store i Manager ,  Occupation of Wife  housewife  housewife  housewife  housewife  housewife  housewife  housewife  housewife  Length of Present Marriage  10 years  11 years  8 years  10 years  7 years  17 years  2 years  19 years  none  none  none  none  none  none  once  none  none  none  none  once  none  none  twice  none  No. of times , Husband was 1 Married Previously , No. of times Wife was Married Previously  Clerk  Husband's Religion  A. C. C.  A. C. C. Protestant  Protestant  Protestant  Lutheran  A. C. C.  Protestant  Wife's Religion  A. C. C.  A. C. C. Protestant  Protestant  R. C  Lutheran  A. C. C.  Protestant  , .  ,.  i  - 2-5 -  Case A - Summary Mrs. A. was referred to the Mental Health Centre for symptoms of depression which had been precipitated most recently by her confessing to her husband that a family male friend had been coming to the house privately and been paying amorous attention to her although there had been no sexual relationship.  She had a number of episodes of depression but' i n the past she has res-  ponded to this by clinging closely to her home and family. On this occasion, however, she became so i l l that she needed treatment and was referred to the Clinic. The patient had a deprived background, having been placed into an orphanage at age two.  At age twelve, she l e f t to stay with a family where there  was a lot of sibling rivalry with the natural child.  At seventeen, she l e f t to  become a nurse-maid until the time of her marriage at 21. Mr. A. worked as a produce manager i n a local super market. He was a rather withdrawn man having, himself, a rather deprived childhood. He tended not to be able to look closely into the reasons for certain d i f f i c u l t i e s i n the marital relationship, and when he did look for reasons with the help of the social worker, he was not able to get involved i n meaningful explanations. This couple's social l i f e had been extremely limited, largely because Mrs. A. refused to l e t someone else stay with her children. not gone out socially for a long while.  They had, therefore,  The only friends they had were a married  couple whose friendship they had valued highly. It was this friend, however, who came to v i s i t Mrs. A. and with whom Mrs. A. became emotionally involved. Mrs. A. appeared to prefer father-daughter relationships with men but did not seem to have had these dependency needs met by her husband.  Conse-  quently, she turned to the male friend who was sheltering and protecting towards  - 26 -  her - more like a father than a boyfriend, although she had a greater sexual attraction for the friend than for her husband. There i s evidence that the husband attempted to meet his wife's dependency needs by, according to the wife, treating her as a child, incapable of making decisions. He was inconsistent in this, said his wife, by expecting her, at the same time, to take responsibility. Mrs. A. provided no emotional support for the husband at the time of assessment.  She told him that she did not love him at that point and that only  "time w i l l t e l l " whether, i n fact, she would be able to do t h i s . There was a great deal of dissatisfaction on the part of Mr. A. related to sexual relations.  His wife was unresponsive and cold. Mrs. A. was  f r i g i d and did not seem to enjoy sexual relations. Both Mr. and Mrs. A., during the assessment period, were making plans to separate.  Schedule A Occ: Housewife Religion: A. C. C.  1  - Mrs. A. Age 31 years - married 10 years. (Patient)  Source of Stress  Value Threatened  Duration of Stress  Response to Stress  Effect on Reciprocal Relationship of Husband and Wife  Loss of parents during childhood.  Parental affection and dependency.  10 years in childhood.  Cverprotection of own children - w i l l not allow other person to look after them so she can go out with husband - seeking dependent relationships.  Wife sees husband as father figure husband treats her like child.  Husband does not meet her dependency needs.  Security through attention and affection from male fatherfigure."  Since early part of marriage.  Seeks satisfaction of needs outside of marriage.  Loss of mutual affection, emotional distance between husband and wife.  Family friend paying amorous attention to her.  Loyalty to husband.  One year.  Feelings of guilt; confession to husband; symptoms of mental i l l ness as recognized by doctor.  Mutual feelings of anger.  a form of behavior which suggests inability to make decisions and a marked inclination to lean on others for advice, guidance and support. a male who, in the mind of a person, serves as a substitute for a father.  Schedule A£ - Mr. A. Occ: Dept. Manager i n Chain Store Religion: A. C. C.  Source of Stress  Wife's failure i n performing household tasks to his , standard.  Age 3 7 years - married 1 0 years.  value Threatened  Duration , of Stress  Image of "good homemaker".  1 Since j marriage.  Wife's apparent failure as mother.  Image of "good mother".  Unsatisfactory sexual relations.  Sexual satisfaction.  1 Since  Wife's affair with his friend.  Loyalty of wife.  ! One month.  Wife's mental illness.  Four years.  \ Dissatisfaction with /wife; criticism of / wife as homemaker and \ mother; undermining \wife's authority / with children.  Effect on Reciprocal Relationship of Husband and Wife Mutual anger; loss of affection; emotional detachment; mutual sexual dissatisfaction.  1 marriage. !  : Health of wife.  Response to Stress  (Relative of patient)  One month.  Anger; loss of confidence in wife.  Mutual dissatisfaction with the relationship.  Wish to escape from total situation.  Plans for separation being considered by both partners.  -  29  -  Case A - Assessment in Terms of Stress Concepts Mrs. A. has a deprived background, having been placed i n an orphanage after the loss of her parents at the age of two.  This deprivation was a source  of stress to Mrs. A. at that time, threatening her need for parental affection and for dependency. Because this source of stress continued through her formative years, she could not find a satisfactory resolution of these needs and continued through to adulthood and found expression in the close interaction of marriage and family l i f e .  Her response to this source of stress was seen i n  her seeking a dependent relationship with her husband, in this way satisfying her childhood needs for affection and dependency, including the oedipal strivings for her father. She also overprotected her children, i n this way satisfying vicariously her dependency needs. This response to stress on the part of Mrs. A., however, was not satisfying the husband's needs, nor was i t meeting his standards of what a wife's role should be.  Consequently there were mutual feelings of frustration,  and the marriage relationship was not as close and warm as both husband and wife would have wanted i t to be. This lack of closeness continued to threaten Mrs. A.'s value of security through the affection of a father figure, and she responded to this by turning outside of her marriage to have her needs met.  She appreciated the  amorous attention of her husband's closest friend, who was nine years her senior. Although there were no sexual relations i n this affair, i t threatened Mrs. A.'s value of marital f i d e l i t y .  To this she responded with intense guilt and finally  with acute psychiatric depression for which she was admitted to the Centre.  A child's sexual interests in the parent of the opposite sex.  - 30 -  Mr. A., who valued a high degree of order in the household and who held rather r i g i d expectations of the role of a "good homemaker", saw these values threatened by his wife's casual approach to keeping house. continued since their marriage.  This had  Besides this, Mr. A. was displeased with his  wife's handling of the children, failing to see her as the "good mother" he would have wished her to be.  Because his wife was sexually unresponsive, his  value of sexual fulfillment for himself was threatened. To these sources of stress, Mr. A. responded with a good deal of anger which was not directly expressed, but was shown by his undermining Mrs. A.'s one area of competence (as she saw i t ) - that was her ability to deal with and train her children. The wife's affair with.Mr. A."s "best friend" was a threat to his value of marital loyalty.  His friend apparently had come to the house when  Mr. A. was at work and Mr. A. responded to this with anger and with threats to discontinue the marriage.  Some anger seemed to have been internalized i n the  form of an ulcer which apparently erupted during periods of stress.  - 31 -  Case B - Summary Mrs. B. was referred to the Mental Health Centre because of symptoms of depression which had been building up over a number of years.  She suffered  from extreme feelings of unworthiness and was overly dependent on her husband. She came from an unhappy home where the mother dominated the whole scene, and everyone had to be submissive, including her father. Her mother possibly rejected her, made her feel inferior, but controlled her l i f e , even after marriage. Mr. B. i s a successful salesman who seems to have needed his wife's dependency to make himself feel more capable.  At the same time, he dislikes the  other complications of having a dependent wife.  On the surface he was kind and  gentle to his wife (except for occasional temper outbursts), but there were signs of rather angry feelings toward her. Mrs. B. required a great deal of emotional support from her husband, which»he gave on a superficial level, but she was able to give l i t t l e i n return. In this way,  the marriage was quite out of balance.  She was failing i n her role  as homemaker due to her feelings of depression and was not able to be the social partner for her husband that he wished. l i t t l e satisfaction in sexual relations.  Sexually, she was frigid and found Because she was unresponsive, her hus-  band found l i t t l e satisfaction as well, and during the course of the assessment, spent a great deal of time ventilating his feelings about this.  Schedule B  1  - Mrs. B.  Occ: Housewife Religion: A. C. C.  Age 37 years - married 11 years.  (Patient)  i  Source of Stress  Value Threatened  Duration of Stress  Response to Stress  Effect on Reciprocal Relationship of Husband and Wife  Domination of her stern, controlling mother.  Independence and feeling of self-worth.  Since early childhood into marriage.  Low sense of self-worth; intense, unexpressed anger toward mother; eventually psychiatric depression ; need for dependent relationships.  Wife excessively dependent on husband to which husband responded by overprotecting her; both unhappy with this relationship.  v  Excessive dependency on husband; her own inadequacy to perform role.  Her percept of culturally prescribed role of wife.  Progressively since marriage.  Anxiety and guilt; as a result of which she required continued support and encouragement from husband.  Mutual dissatisfaction with the dependent relationship; sexual incompatibility.  Sexual frustration.  Sexual gratification.  Since marriage.  Anger toward husband although this was turned inward or repressed; feelings of inadequacy as a woman.  A mutual h o s t i l i t y , ^ though well defended against; expressed in such statements as "we never did get along.  this consists of feelings of painful rejection, anxiety, d i f f i c u l t y in thinking, and retardation of physical activity, defences in this framework refer to mental processes which serve to protect the individual against danger arising from his impulses or feelings.  w  Schedule B Occ':- Regional Sales Manager Religion: A.' C.< C,  2  - Mr. B. Age 32 years - married 11 years.  (Relative of Patient)  ;  Source of Stress  Value Threatened  Duration of Stress  Response to Stress  Effect on Reciprocal Relationship of Husband and Wife  Dependency of wife.  Mature behaviour on part of wife.  Since marriage.  Low regard for wife, but efforts to meet dependency needs.  Emotional distance between husband and wife. Increasing loss of trust.  I r r i t a b i l i t y and depression of wife.  Healthy, responsible Six behaviour on part years. of wife.  Sexual frustration.  Sexual satisfaction. Since marriage.  Anger; periodic temper outbursts, followed by i "redoubled efforts to coax wife into a better state." Anger towards wife; sees this as a core problem in the marriage.  Mutual feelings of anger; though these are strongly defended.  Mutual h o s t i l i t y , though this i s well defended against.  - 34 -  Case B - Assessment in Terms of Stress Concepts Mrs. B. came from an unhappy home i n which the mother dominated the whole scene and where everyone had to be submissive including the father. Mrs. B., too, had been controlled by her mother not only as a child, but even as an adult; she had been rejected by her mother emotionally i n spite of the over-protectiveness of the mother. In this x^ay Mrs. B.'s desire to become i n dependent and to develop feelings of self-worth were threatened by her mother's behaviour and to this she responded with a deep sense of worthlessness, a continued need for dependent relationships.  At the same time, too, she developed  intense feelings of anger toward her mother. In the marriage this need for dependent relationships was seen i n Mrs. Bo's demand for a great deal of emotional support from her husband, which he gave by over-protecting her, but she was able to give l i t t l e in return.  The  marriage in this way was quite out of balance. Mrs. B.'s anger, on the other hand, was not given overt expression and she internalized this.  Subsequently i t turned into a psychiatric depression.  The excessive dependency on her husband and her own inadequacy to perform her role as wife became a source of stress i t s e l f for Mrs. B. in that i t contradicted what she saw as the culturally prescribed role of wife.  She res-  ponded to this with anxiety about her inadequacy and with guilt about her inab i l i t y to perform her role.  This in turn led to continued need for support and  encouragement from her husband, creating a vicious circle of cause and effect from which she found i t impossible to escape.  There was mutual dissatisfaction  with this dependent relationship and directly and indirectly, i t led to unsatisfactory sexual relationships. The sexual frustration, which had existed throughout the marriage, led,  - 35 -  on Mrs. B.'s part, to anger toward her husband although this was turned inward, or repressed.  It also confirmed her feelings of inadequacy as a woman. The  sexual frustration seemed to become the focus for mutual hostility in the marriage, although this was defended against. Mrs. B., for example, expressed her anger only occasionally and with some support i n the interviews through such statements, made with feeling, "We never did get along*', Mr. B, recognized his wife's dependency needs and overprotected her. It was a source of stress for him, however, expecting i n i t s place a more mature level of behaviour on the part of his wife.  Although his f i r s t response had  been to meet his wife's dependency needs, i t had later also resulted i n a low regard for his wife as he saw her more as a dependent child than a mature adult. In the marriage relationship, this led to emotional distance between husband and wife and an increasing loss of trust in each other. The development of psychiatric symptoms in Mrs. B., including increased i r r i t a b i l i t y and depression, also became a source of stress for Mr. B.  The  symptoms threatened his value of healthy, responsible behaviour on the part of his wife.  He responded to this stress with feelings of anger which were expres-  sed only periodically i n temper outbursts.  These outbursts were frightening to  him, however, and were followed by "redoubled efforts to coax his wife into a better state". Sexual frustration was a significant source of stress and, according to Mr. B., played an important part in the marital problem.  The lack of f u l f i l l -  ment i n this area led to increasing anger toward his wife although at the time of assessment, he was well defended against this feeling of anger.  - 36 -  Case C - Summary Mrs. C. was referred to the Mental Health Centre by her physician for symptoms of depression, including sleeplessness, chronic tiredness, inability to make decisions, and general feelings of anxiety. This couple met five years before their marriage when the wife began working in the business operated by her present husband. The business has played an important part i n whatever happened i n the family, particularly at the time just prior to referral to the Mental Health Centre, when Mrs. C. again had to return to the business to help with, the work. The resulting d i f f i c u l ties led to her episode of mental illness, although there was a long history of feelings of tension and anxiety whenever some d i f f i c u l t situation arose. Mrs. C. appeared to be a rather insecure person who f e l t rejected, or at least feared rejection tremendously.  She appeared to have developed a  lot of hostile feelings because of this insecurity and unnurtured dependency needs from earliest childhood. Mr. C., who operated a small business, was rather passive, well defended against anxiety, and found i t d i f f i c u l t to express his feelings about matters related to the marriage.  The underlying problem seems to have been  the relationship between Mr. and Mrs. C. i n that neither Mr. C. nor his wife were facing i n any direct manner the sources of conflict between them. A l though the question as to whether or not Mrs. C. should be working in the business seems to be the source of difficulty from the couple's point of view, this is not l i k e l y the real source of the problem. The chief source of the problem seemed to l i e i n the failure i n communication between the spouses.  For this  reason i t was decided that they should be seen i n joint interviews by a caseworker.  Schedule C± - Mrs. C. Occ: Housewife Religion: "Protestant"  Age 31 years - married 8 years.  Source of Stress  Value Threatened  Duration ! of Stress  Separation of parents and general instability of social situation in early l i f e .  Security and consistency in family relationships .  Through formative years.  1 Return to work i n her husband's business and discovery of the poor state of the business finances.  Heed for security and dependence on a successful person.  Inability to communicate her feelings of anger toward her husband.  Heed for expressing pent-up feelings.  I Response to Stress  (Patient)  Effect on Reciprocal Relationship of Husband and Wife  Continued search for security, including through marriage to an older man.  Dependency of wife on a strong, successful male figure. There was a need for her to see him as successful.  Intense anxiety about the insecurity.  There are feelings of anger about this whole situation, but patient i i s afraid of expressing these.  Internalizing the anger and developing psychiatric symptoms.  Husband upset about the symptoms, but i s unable to express anger. Thus both partners have unexpressed mutual hostility resulting i n emotional distance, and threatening the marriage i t s e l f .  .  j Six months.  Since early marriage.  Schedule C Occ*': E l e c t r i c i a n Religion: "Protestant"  Source of  Stress  Wife's i r r i t a b i l i t y , a n x i e t y and o t h e r symptoms o f a p s y c h i a t r i c nature.  - Mr. Age  C.  kk  years - married  8 years."  ( R e l a t i v e of  Patient)  V a l u e Threatened  Duration of Stress  Response t o S t r e s s  E f f e c t on R e c i p r o c a l Relationship of Husband and W i f e  H e a l t h and mature b e h a v i o u r on p a r t of wife.  Several years.  F e e l i n g s o f anger about w i f e ' s b e h a v i o u r which he i s unable t o verbalize.  Emotional distance; t e n s i o n i n husbandwife relationship though t h i s i s n o t d i r e c t l y expressed by e i t h e r , .  Since marriage.  E s c a p i n g from the home on b u s i n e s s c a l l s , e t c . , t o reduce p o s s i b i l i t y o f expressing f e e l i n g toward w i f e .  Increased t e n s i o n ; i n c r e a s e d mutual anger.  I n a b i l i t y to Need f o r communicate f e e l i n g s '; v e n t i l a t i o n o f o f anger toward feeling. wife. ;  2  - 39 -  Case C - Assessment i n Terms of Stress Concepts Mrs. C. has had a history of rejection by parents, her mother having been married four times, and has had a rather unstable l i f e i n her formative years when a child normally values the security of parent figures and the consistency i n the social situation which goes with this security.  Because this  stress factor continued throughout the formative years, there was at no time a satisfactory resolution of this need for protection and dependency. she entered adulthood s t i l l i n search of this.  Consequently  This led her to "romantic affairs"  with two men, both considerably older than herself and whom she saw more as protective father figures than as lovers.  She married the second of these and  seemed to be expressing through this her need for security from a father substitute - this being her response to the stress of parental rejection during her childhood. Although Mrs. C. had shown some symptoms of depression such as anxiety and retardation of mental and physical activity over a long period of her marriage, a real crisis arose when, on going back to her husband's business as bookkeeper she discovered that her husbarid's business was actually doing very poorly.  She suddenly discovered that her security and her dependency on her hus-  band was threatened as the business on which the security rested was faced with bankruptcy.  Mrs. C.'s response to this stressful situation was intense anxiety  as i t seemed to remind her of earlier loss of security from parent figures. She now became quite resentful toward her husband as a result of the present threat, but she was unable to express her real feelings about this to her husband. This inability to communicate her feelings of frustration and anger toward her husband on whom she was dependent became a source of stress i t s e l f . .She wished to express her pent-up feelings, but because of her own need for  _ 40 -  approval from the person on whom she was so dependent, and because of her husband's inability to express anger as well, Mrs. C. responded by internalizing her anger and by developing psychiatric symptoms."" Until his wife had come to work as bookkeeper in the business, Mr. C. had been able to escape from his wife by spending extra time at his work. However, when she began working for him again and her psychiatric symptoms became more acute because of her anxiety, Mr. C. began to see his wife's symptoms as a source of stress.  His value of health and mature behaviour on the part of his  wife was threatened. He responded to this, over time, with increasing feelings of anger.  As with his wife, Mr. C. was unable to express this anger toward his  wife and was able to set defences around i t for a time. Eventually, however, his defenses against this anger seemed unable to hold against the increasing pressure.  He responded to this threatened explos-  ion by escaping from contact with his wife as much as possible to give less occasion for i t to find expression. In both husband and wife, then, the mutual anger seemed to be building up.  As the wife's ego defenses seemed weaker than her husband's, i t was Mrs. C.  who was the f i r s t to break under the stress in the form of mental illness for which she was referred to the M. H. C.  The term "psychiatric symptoms" as used i n this paper refers to behaviour on the part of a person which indicates the presence of mental illness as recognized by a psychiatrist.  -Pl-  ease D - Summary Mrs. of  D. was r e f e r r e d t o the M. H. C. b y h e r p h y s i c i a n w i t h  t e n s i o n symptoms based on m a r i t a l d i f f i c u l t i e s .  p r e v i o u s l y a t age 19  complaints  She had been m a r r i e d  " t o g e t away from h e r c o n t r o l l i n g mother" b u t t h i s  first  m a r r i a g e had ended i n d i v o r c e , although M r s . D. s t i l l remained i n t e r e s t e d i n her f i r s t husband and f r e q u e n t l y saw him a f t e r h e r second marriage. re-married  some t e n y e a r s p r i o r t o r e f e r r a l t o the M. H. C.  Mrs. D.  as an a g g r e s s i v e , c o n t r o l l i n g woman whose a n x i e t y was p r e c i p i t a t e d by  She had presented her-nor-  m a l l y p a s s i v e husband's o u t b u r s t o f h o s t i l e a g g r e s s i o n , s u i c i d a l t h r e a t s and impotency. M. H. C.  T h i s had begun some one y e a r b e f o r e t h e time o f assessment at t h e Mrs. D., over t h e p a s t few y e a r s when t h e m a r r i a g e had appeared t o be  g o i n g b a d , had become a d d i c t e d t o b a r b i t u r a t e s which had o r i g i n a l l y been p r e s c r i b e d by h e r p h y s i c i a n .  She had been h o s p i t a l i z e d on t h r e e o c c a s i o n s f o r t h i s .  Mr. D., d u r i n g t h e f i r s t to  express  few y e a r s o f h i s m a r r i a g e ,  had been unable  h i s f e e l i n g s o f anger about h e r s e e i n g h e r former husband.  I n the  p a s t y e a r , however, he had become a g g r e s s i v e l y h o s t i l e toward h i s w i f e and about t h i s t i m e had become s e x u a l l y impotent. S i n c e t h i s time, off,  t h e r e have been v i o l e n t arguments which were t r i g g e r e d  and u s u a l l y c e n t e r e d around, t h e s e x u a l problem w h i c h both saw as c e n t r a l  in their d i f f i c u l t i e s .  I n the arguments, Mr. D. blamed h i s w i f e f o r h i s impo-  t e n c y , and Mrs. D. was v e r y d e p r e c i a t i n g and a c c u s i n g towards h e r husband.  The  husband's t h r e a t s o f v i o l e n c e toward h i s w i f e and toward h i m s e l f u s u a l l y came out o f these  arguments.  Schedule D Occ: Housewife Religion: Protestant  1  - Mrs. D. Age 41 years - married 10 years.  (Patient)  Duration of Stress  Response to Stress  Effect on Reciprocal Relationship of Husband and Wife  Husband's unwilling- Need for having ness to express husband express feelings, positive his feelings and or negative, i n assert himself. early part of their marriage - general passivity.  First nine years of marriage.  Fear - that husband was, i n fact, angry. There were some anxiety periods for which she sought medical help and medication.  Gradual building up of unexpressed anger in both husband and wife - expressed f i n a l l y i n husband's impotency and i n arguments.  Husband's impotency. Husband's sexual adequacy.  One year.  Fear - that husband i s using this as a means of attacking her.  Expressed h o s t i l i t y in the form of violent arguments.  Attacks of husband i n the violent arguments between husband and wife, and i n this she sees herself rejected by him.  One year.  Anxiety about the rejection, but the wife denies to herself that she feels rejected. Projects blame onto her husband. Denial i s seen i n her becoming addicted to barbiturates.  Increased strain on the relationship leading to their looking for help.  Source of Stress  Value Threatened  1  Need for acceptance by her husband.  withdrawal or escape as an adaptation to a d i f f i c u l t situation.  Schedule D - Mr. D. 2  Occ^.: Clerk Religion: Protestant  Age 51 years - married 10 years.  Source of Stress  Value Threatened  Duration of Stress  Wife* s continued interest in her f i r s t husband.  Wife's loyalty.  Early years of marriage.  Mr. D's sexual dissatisfaction in present marriage.  Desire to have sexual satisfaction.  Mr . D's impotency.  Feeling of manhood.  Response to Stress  i  (Patient)  Effect on Reciprocal Relationship of Husband and Wife  Anger toward his wife.  Emotional distance created between husband and wife and unsatisfactory sexual relations.  Seven years.  Feelings of anger, for some time not expressed, but for one year prior to assessment, he was expressing this i n violent arguments. Also expressed i n his impotency.  Progressively increasing hostility, f i n a l l y coming to open clash between husband and wife.  One year.  Feeling of inadequacy in masculine role, projecting blame on his wife; suicidal threats.  Hostility between husband and wife.  -1*1* -  Case D - Assessment in Terms of Stress Concepts Mrs. D. f i r s t became concerned about the marital relationship when her husband was unable to express any feelings, either positive or negative, tox'/ard her continuing contact with her f i r s t husband during the early years of the marriage.  Apparently Mrs. D. had been married previously at age 19  "to get away from her controlling mother", but this marriage had ended in divorce.  Mrs. D. had remained interested in her f i r s t husband and frequently  saw him after her second marriage.  Mr. D.'s passivity toward her contact with  her f i r s t husband threatened her value of seeing her husband express his feelings and asserting himself i n relation to her.  This passivity had carried on for the  f i r s t nine years of marriage and during the course of time, Mrs. D. had built up a considerable degree of anxiety in response to this stress.  She sought medical  help for the anxiety and was given medication to control i t . About a year before the time of assessment, the husband had an outburst of hostility and anger, where he threatened his wife and threatened suicide. This had been followed by impotency on the part of her husband. Both the husband's impotency and his expression of anger became sources of stress for Mrs. D. The breakdovm of her husband's sexual v i r i l i t y threatened her value of sexual adequacy on the part of her mate. This stress had lasted about a year and had increased Mrs. D.'s anxiety i n that she f e l t that her husband was using this means to attack her.  The whole sexual problem became the core of violent' argu-  ments between husband and wife i n which both were angry and attacking. The verbal attacks by Mr. D. became a source of stress for Mrs. D. in that she saw this as a rejection of herself,by her husband. tance was thus threatened.  Her need for accep-  To this she responded with intense anxiety, and a l -  though she tried to deny this by projecting blame on her husband, she was not  - 45 -  s u c c e s s f u l i n t h i s and sought escape f r o m t h e problems b y t a k i n g b a r b i t u r a t e s t o w h i c h she then became a d d i c t e d . F o r Mr. D., t h e f i r s t major s o u r c e o f s t r e s s i n t h e m a r r i a g e was h i s w i f e ' s c o n t i n u e d i n t e r e s t i n h e r f i r s t husband.  During the f i r s t nine  years  o f m a r r i e d l i f e he had been u n a b l e t o e x p r e s s h i s f e e l i n g s o f anger about  this  a l t h o u g h he h a d , i n f a c t , a g r e a t d e a l o f i t as h i s v a l u e o f m a r i t a l l o y a l t y had been t h r e a t e n e d b y h i s w i f e ' s  behaviour.  P o s s i b l y M . D.'s anger toward h i s w i f e was e x p r e s s e d , r  i n part, i n  t h e u n s a t i s f a c t o r y s e x u a l r e l a t i o n s h i p o v e r seven y e a r s b e f o r e t h e assessment. He was.being an u n s a t i s f y i n g p a r t n e r as a way o f p u n i s h i n g h i s w i f e , a l t h o u g h he was h i m s e l f a l s o s u f f e r i n g t h e same punishment. The u n s a t i s f y i n g s e x u a l r e l a t i o n s h i p was t h e n a source o f s t r e s s i t s e l f f o r Mr. D., t h r e a t e n i n g h i s need f o r s e x u a l s a t i s f a c t i o n .  T h i s was a g a i n  responded t o by f e e l i n g s of anger t o w a r d h i s w i f e w h i c h o n l y r e i n f o r c e d t h e f e e l i n g s already present.  This pyramiding  o f anger and punishment was  climaxed  about a y e a r b e f o r e assessment b y a sudden o u t b u r s t o f anger b y Mr. D., and b y becoming i m p o t e n t t o w a r d h i s w i f e . s t r e s s of the marriage  T h i s seemed t o be t h e f i n a l r e s p o n s e t o t h e  relationship.  Mr. D., however, seemed n o t o n l y t o be p u n i s h i n g h i s w i f e w i t h h i s impotency, b u t a l s o c r e a t i n g a source of s t r e s s f o r h i m s e l f .  He had always  p r i d e d h i m s e l f i n h i s s e x u a l prowess and f e l t p a r t i c u l a r l y t h r e a t e n e d b y h i s impotency.  He responded t o t h i s w i t h f e e l i n g s of i n a d e q u a c y as a man, w i t h  v e r b a l a t t a c k s on h i s w i f e and w i t h s u i c i d a l t h r e a t s . The d i s t u r b a n c e i n t h e m a r r i a g e  e v e n t u a l l y m o t i v a t e d b o t h husband  and w i f e t o l o o k f o r h e l p w i t h t h e p r o b l e m .  - 2*6 -  Cage E - Sunimary Mrs. E. was referred to the M. H. C. by her physician f o r symptoms of depression, headaches, and i r r i t a b i l i t y which had continued since the beginning of her marriage some seven years before.  She was a French-Canadian  Catholic, who had l o s t her mother by death at the age of nine.  Subsequently  she had a poor r e l a t i o n s h i p with her stepmother by whom she was rejected to the point where she was placed by her r e j e c t i n g alcoholic dentist father into a church boarding school where she remained u n t i l age seventeen.  From her  childhood she had feelings of unworthiness, i n f e r i o r i t y , and i n a b i l i t y to seek satisfaction i n r e a l i s t i c relationships.  At the time of assessment, she was  found to be insecure, dependent and f e a r f u l of any close relationships with people. She married, at age 22, a man  she did not love and d i d not respect,  but married him because he seemed lowly enough and she f e l t she could out-shine him.  She looked', on the other hand, f o r a f f e c t i o n , acceptance and a parental  quality of strength from her husband. The husband was found to be an immature, s o c i a l l y insecure man had not wholly emancipated from his mother.  who  He projected blame f o r h i s unhappy  marriage e n t i r e l y on his wife, and refused to "have h i s personality changed" to improve the marriage. The marriage i t s e l f had been founded on a very weak footing, both partners f e e l i n g i n f e r i o r , both seeking a dependent r e l a t i o n s h i p on the one hand and on the other hand, f e e l i n g the need to "prove themselves".  Consequently  they provided no emotional support f o r each other. The couple had very few s o c i a l contacts, and any partying was  always  followed by harsh c r i t i c i s m by the wife of her husband's i n a b i l i t y to meet  -k7 the occasion with any degree of social f a c i l i t y .  The husband and wife in no way  can be said to. be social partners for each other and they have no common interests. The husband managed to provide a good living for the family; the wife seemed to look after the affairs of the home adequately.  Their sexual l i f e  was "repulsive" to Mrs. E. and Mr. E. stated that he could not expect satisfaction from sexual relations when the rest of the marriage was going so poorly. Although Mr. and Mrs. E. were of different religions, this did not interfere in their marriage as the church was not really considered an important part of l i f e .  Schedule E  1  - Mrs.  E.  Age 29 y e a r s - m a r r i e d 7 y e a r s .  Occ.: Housewife R e l i g i o n : R. C.  Source o f S t r e s s  Value  R e j e c t i o n by b o t h f a t h e r and mother.  Threatened  (Patient)  Duration of S t r e s s  Response t o S t r e s s  E f f e c t on R e c i p r o c a l R e l a t i o n s h i p of Husband and W i f e  Need f o r acceptance and l o v e .  Since early childhood.  Low sense o f self-worth» shy. S t r o n g dependency needs. M a r r i e d p e r s o n whom she saw as beneath her, t o get a f e e l i n g of s e l f - w o r t h .  Wife f e e l s s u p e r i o r t o husband, does n o t r e s p e c t him. Husband responds w i t h hostility.  Her marriage t o a man she d i d n o t l o v e , and who d i d not l o v e h e r .  M a r i t a l l o v e and happiness as taught by the c u l t u r e i n which she l i v e d .  Since marriage.  F e e l i n g of f r u s t r a t i o n and tremendous f e e l i n g o f anger toward h e r husband.  M u t u a l anger and arguments. "An armed truce"•  The c o n f l i c t i n the marriage.  Her need f o r b e i n g understood and appreciated.  Progressively since marriage.  E m o t i o n a l s t r a i n and p s y c h i a t r i c symptoms f o r which she sought help.  Sex was " r e p u l s i v e " to both. Vicious c i r c l e of h o s t i l i t y , c o n f l i c t , emotional strain. Threat of break-up o f m a r r i a g e .  Schedule Eg - M r . E . Occ ,: Accountant Religion: Protestant  Age 39 y e a r s - m a r r i e d 7 y e a r s .  ?  , Source o f  Stress  (Relative  Patient)  E f f e c t on R e c i p r o c a l Relationship of Husband and W i f e  V a l u e Threatened  Duration of Stress  Response to  L a c k o f common i n t e r e s t s and concerns*  Sharing of interests.  Since marriage.  Withdrawal from w i f e emotionally. Pursuit of own i n t e r e s t s .  Failure in communication. mutual warmth.  Depreciative comments. Accusations, criticisms o f him by w i f e .  Need f o r r e s p e c t from w i f e .  Progres1 sively since j marriage.  F e e l i n g s of a n g e r , w i t h drawal as much as p o s s i b l e , and r e s i g n a t i o n t o t h e situation.  Lack o f mutual respect. "Unpleasant, unsatisfactory union."  ! H i s need f o r a | warm, p r o t e c t i n g relationship,  1 Progres! sively since j marriage.  jlntense h o s t i l i t y , a c c u i s a t i o n o f w i f e f o r the [ d i f f i c u l t i e s , escape from the problem i n g a r d e n i n g and g o l f . .  Complete a l i e n a t i o n of the p a r t n e r s .  The c o n f l i c t o f the marriage.  1  Stress  of  No  i  - 50 -  Case E - Assessment in Terms of Stress Concepts Mrs. E. has a long history of emotional rejection in early childhood. Her mother had died when Mrs. E. was nine years old.  Subsequently she  had a poor relationship with her stepmother who rejected her and who, together with the g i r l ' s alcoholic dentist father, sent her to a boarding school as a f i n a l act of rejection.  This early experience of rejection proved a source of  intense stress for her, threatening her need for acceptance and love. Her reaction to this stress included feelings of unworthiness and inferiority and inability to have satisfaction in relationships with other people. strong dependency needs and insecurity i n social relationships.  She had  She respon-  ded to early rejection, also, by marrying a man whom she saw as beneath herself i n his social relationships i n order that she could have the feeling of being better than someone else.  At the same time she wanted to have her dependency  needs met by her husband who was ten years her senior.  The record showed that  Mrs. E. was looking for affection, acceptance and a parental quality of strength i n her husband. Her marriage, in that she was trying only to get something out of i t and give no love in return, became a source of stress i t s e l f . her culturally imposed value of marital love and happiness.  It threatened She saw, as she  compared her marriage with other marriages, that hers was not giving the satisfaction that other people seemed to be getting from theirs.  The unhappy marriage,  of course, also threatened her continued need for support and for a satisfying dependent relationship.  Her response to the stress of the marriage was a trem-  endous feeling of anger toward her husband. As this was a mutual feeling, there were many explosive situations and some arguments, although there was some restraint in this.  Thus an "armed truce", as Mrs. E. called i t , existed between  - 51 Mr. and Mrs. E. Finally, the conflict of the marriage became i t s e l f a source of stress for Mrs. E. as i t continued progressively to deprive her of her need for being understood and appreciated. As this had developed progressively since her marriage, her response in terms of emotional strain and psychiatric symptoms i n creased.  The symptoms only increased again the mutual anger of husband and  wife so that a vicious circle of hostility, conflict and emotional strain developed which led .eventually to a consideration of actually breaking up the marriage. For Mr. E. the f i r s t significant source of stress seemed to be the discovery that he and his wife were not satisfying each other's social needs. They had very few social contacts and any partying was followed by harsh c r i t i cism by the wife of her husband's inability to meet the occasion with any degree of social f a c i l i t y .  Also, Mr. and Mrs. E. could not meet each other's social  needs when by themselves as they had no common interests and concerns which they could share.  This, was particularly stressful for Mr. E., as he saw a value  in sharing such interests.  He responded to this stress by withdrawing from his  wife emotionally and by pursuing his own interests.  Thus there was a breakdown  in communication and an increasing emotional distance between the partners. Because Mrs. E. had no respect for her husband and because she c r i t i cized him for his social ineptitude, Mr. E. f e l t under great stress as his need to have his wife respect him and accept him was threatened.  He responded to  this with feelings of anger and by withdrawing from interaction with his wife as much as possible. To him the marriage became an "unpleasant, unsatisfying union". The conflict which developed between husband and xtfife became a source  - 52 -  of stress for Mr. E. Because he had a need for a warm, protecting relationship with a mother-figure, he f e l t this value threatened by the marital conflict. His response to this was intense feelings of anger toward his wife which he showed by accusing his wife of being responsible for the d i f f i c u l t i e s of the marriage.  He responded also by continuing to escape from the situation to  the point where there was complete alienation of husband and wife.  - 53  -  Pa,s$ F - Sujumary Mrs. F. was referred to the M. H. C, by a practicing psychiatrist. She was admitted in a rather severe phobic state of a year and a half's duration.  She was of Swedish background, having immigrated to Canada some six  years before assessment at the Clinic.  Her phobia was centred around her fear  of k i l l i n g her eleven year old son and these had begun following the death of a very close friend who had been a mother figure for her. The dynamics leading to her present illness appeared to be numerous deaths of immediate relatives during her formative years, particularly those of her father at the age of four, her mother at the age of thirteen and the near death of her brother at age six. Besides this, the transculturation from Sweden to Canada was very threatening to her. Mr. F. was seen i n interviews, although he was rather reluctant to become involved. He was a very rigid individual who found i t most d i f f i c u l t to look at himself and at his part in the marriage, being quite threatened with the prospect of having to change his own feeling about the marriage relationship and about assuming more responsibility for his wife. He resented his wife's dependency on him, being himself a somewhat insecure, dependent person. The record says l i t t l e about the marriage relationship before Mrs. F.'s illness, except a comment by Mrs. F. that they were "happily married". It would appear that the marital difficulty was largely centred around the woman's illness.  Mrs. F. became more dependent on her husband since her illness  and she indicated that she had no fears or phobias when he was with her.  She  recognized her dependency on him and looked upon him as something of a protector.  Mr. F. resented his wife's new dependency through her illness and  threatened her with punishment whenever she made a slight movement to assert  - 54 -  herself i n order to have her dependency needs met.  Because she could not  have her dependency needs met, Mrs. F. looked for support by seeking professional help, but her husband resented these efforts to change the situation because, i t seemed, he was afraid of getting involved i n the attempt to help him see his part i n the picture or to change himself i n any way. Through the early part of the marriage then, the partners had provided for each other what appeared to be a source of emotional support.  This  balance, however, was upset by the increasing dependency of the wife and by the appearance of her psychiatric symptoms. Similarly there was a breakdown i n both partners of the role of social partner for the spouse. Mr. F. was a good provider but this role was threatened by the tremendous medical expenses in regard to his wife. Mrs. F.'s role as homemaker seemed to be quite adequately f i l l e d u n t i l her breakdown. The record had nothing to say about the spouses' roles as sexual partners. In brief, the breakdown of the husband and wife roles became noticeable only with the appearance of psychiatric symptoms i n Mrs. F.  Schedule  - Mrs. F. Age 39 years - married 17 years. (Patient)  Occ: Housewife Religion: Lutheran  Effect on Reciprocal Relationship of Husband and Wife  Source of Stress  Value Threatened  Duration of Stress  Response to Stress  Early separation from and death of parents.  Need for dependency on parents during formative years. Need for father during.oedipal period.  Since age four.  Dependent relationContinued demand for close , ship with husband and dependent relationalthough this seemed ships with parent satisfactory to figures. Later, phobic both. reaction.  | Separation from ; native country.  Continued need for support from people around her and from total social situation.  Five years.  Difficulty in acculturation to new country, withdrawal from the new environment.  I Death of mother ! figure.  Dependency needs.  Two years.  ; Threatened 1 rejection of • husband. !  Intensified dependency needs.  One and a Flight into the protechalf years. tion of the hospital and Mental Health Centre.  Breakdown of defences phobias. Greatly intensified need for I protection and support.  Increased dependency . on husband.  Husband unwilling to accept the added dependency needs; punitive toward wife, i threatened rejection. Rejection of wife ; by husband. 1  Schedule F Occ.: Carpenter Religion: Lutheran  2  - Mr. F. Age 39 years - married 17 years.  (Relative of Patient)  Source of Stress  Value Threatened  Duration of Stress  Response to Stress  Effect on Reciprocal Relationship of Husband and Wife  Increased dependency of wife and her inability to meet his dependency needs.  Need for mutually dependent relationship with wife.  Progressively over five years.  Punitive toward wife expressed i n his refusal to pay more medical bills.  Breakdown of the mutually satisfying dependent relationship.  Wife's symptoms of illness.  Healthy, supportive wife.  Two years.  Rejection of wife.  1 Threatened breakup [ of marriage. ___  i  -  57 -  Case F - Assessment i n Terms of Stress Concepts Mrs. F. had suffered the loss through death of several Immediate relatives during her formative years, particularly those of her father at the age of four, her mother at the age of thirteen and the near death of her brother at the age of six.  The father's death possibly occurred during the  period of oedipal conflict i n her own development, and with the father's passing, did not alloxtf her to work through her oedipal strivings satisfactorily. The mother's death came before Mrs. F. was ready to become independent of her mother so that her dependency needs were not entirely met either.  She respon-  ded to these sources of stress by continuing to seek dependent relationships with parent figures.  Two examples of such relationships are those with her  husband and with an elderly lady whom she learned to know very well after the couple arrived i n Canada some five years before the assessment at the M. H. C. The dependency relationship with the husband seemed to be a reciprocal one which worked out well until Mrs. F. began to show acute psychiatric symptoms and i n this way tipped the balance by becoming more dependent. The dependency on the older lady became apparent when she closed herself off from forming new relationships as her friends moved away from her neighborhood.  She was close only to this one person on whom she leaned heavily  for support. A second significant source of stress was the separation which Mrs. F. suffered i n moving from her native Sweden to this country. Again her continued need for supportive relationships with familiar people and from the structured social environment x<rere threatened. She responded to this separation by, withdrawing from the new environment and by becoming more dependent on her husband and on the older family friend.  - 58 -  The f i n a l straw i n this developing pattern of stress came when the e l d e r l y friend died about two years before the assessment at the C l i n i c .  Mrs.  F.'s defences seemed to have f i n a l l y broken down i n response to the build-up of stress.  Her husband was unable to give her the added support she required,  however, and he became punitive and r e j e c t i n g , threatening to leave her. This threatened r e j e c t i o n on the part of Mr. F. became a further source of stress to Mrs. F. who had by now greatly i n t e n s i f i e d dependency needs. She responded to t h i s by seeking protection and support at the Crease C l i n i c and at M. H. C.  This again l e d to a t o t a l r e j e c t i o n by her husband who  now  seriously wished to break up the marriage. For Mr. F., his wife's increased dependency needs since a r r i v i n g i n t h i s country had been a source of stress, as Mrs. F. could not meet h i s own dependency needs.  This threatened, f o r Mr. F., the need f o r a s a t i s f y i n g  t u a l l y dependent r e l a t i o n s h i p with h i s wife. punitive toward his wife.  mu-  To t h i s he responded by becoming  "Whenever she made a s l i g h t movement to assert her-  s e l f " , says the record, " i n order to have her dependency needs met, he threatened her with punishment." I t would appear from the record that the m a r i t a l d i f f i c u l t y began around this upsetting of the mutually dependent r e l a t i o n s h i p as the couple stated that they were  happily married before this time.  Mr. F.'s next s i g n i f i c a n t source of stress was the appearance of p s y c h i a t r i c symptoms i n h i s wife shortly a f t e r the death of her f r i e n d .  This  threatened his value of having a healthy, supportive viife.  to  He responded  t h i s by rejecting h i s wife i n that he refused to pay f o r medical treatment  and  by r efusing to give her any other support i n her search f o r treatment at the M. H. C.  r  - 59 -  At this point the situation became intolerable for both husband and wife and Mr. F. threatened to leave his wife who, shortly after the assessment period, escaped from the situation by entering the Provincial Mental Hospital as a voluntary patient.  - 60 Case G - Summary Mr. G. presented problems of lack of control over his temper, a long history of heavy drinking, and recent evidence of memory loss.  There were  strong indications of possible brain damage. This man was a part Indian.  His  mother died when he was three years old and he was then brought up by his aunt who had a large family of her own.  He received l i t t l e love in this home and he  was forced to compete with the other children for whatever affection was available. Mr. G. had been married during the war to an English g i r l while he was serving in the armed forces. His f i r s t wife had come from a prominent family and had found his unstable l i f e quite unsatisfying and eventually had l e f t him.  He remarried some two years before this assessment and the main difficulty  in this marriage, according to the patient and his wife, i s that he has an uncontrollable temper.  This emotional incontinence has become more marked since  his second marriage as has his heavy drinking. The assessment of this man showed that he was an "immature, unsophisticated individual of Indian descent" with low impulse control and weak ego. Mrs. G. was an emotionally dependent person with a deprived background. She had a low sense of self-worth, f e l t that she had never learned the social standards other people had and felt a great need to better herself. She had unmet needs for intense intimate personal affection, had tried to meet these in her relationships with men, but in the process, she always f e l t that she was being exploited and rejected. This was followed by strong guilt feelings. At the time of assessment, Mrs. G. revealed strong ambivalent feelings toward her present husband (the third).  She admired and respected him because  of his physical strength and his " s k i l l as a woodsman". At the same time, she  - 61  -  was c r i t i c a l o f h i s l a c k o f r e f i n e m e n t and h i s l a c k o f a p p r e c i a t i o n o f t h e " f i n e r t h i n g s of l i f e " . Because of t h e unmet dependency needs o f b o t h Mr. and Mrs. G.»  they  were q u i t e dependent on each o t h e r t o t h e p o i n t where one c o u l d say t h a t t h i s was t h e most s i g n i f i c a n t a s p e c t i n t h e development o f p a t h o l o g y i n t h e m a r r i a g e . Mrs. G.  i n d i c a t e d , f o r example, t h a t h e r husband d i d n o t pay enough  t o h e r , and t h a t he d i d n o t t r y t o meet h e r e m o t i o n a l needs.  attention  On t h e o t h e r hand,  she f e e l s t h a t h e r husband sometimes depended on h e r l i k e a s m a l l c h i l d .  The  d i f f i c u l t y seemed t o a r i s e when one p a r t n e r d i d not meet t h e dependency needs of the o t h e r .  Q u a r r e l s between them became more f r e q u e n t as time went on and  as t h e y saw t h a t t h e i r p e r s o n a l needs were n o t b e i n g met, a l t h o u g h t h e y seemed t o i d e n t i f y w i t h each o t h e r t o a p o i n t as each saw t h e o t h e r as an unhappy p e r son l o o k i n g f o r a f f e c t i o n and l o v e .  M r s . G. seemed b e t t e r a b l e t o a c c e p t  this  t h a n h e r husband, a l t h o u g h t h e y were b o t h t h r e a t e n e d b y t h e o t h e r p a r t n e r ' s dependency. D u r i n g t h e f i r s t p a r t o f t h e s h o r t m a r r i a g e , t h e p a r t n e r s had been f a i r l y s a t i s f y i n g s o c i a l p a r t n e r s f o r each o t h e r , b u t t h e husband more and more t u r n e d t o d r i n k i n g and t o " g o i n g out w i t h t h e b o y s " .  M r s . G. a p p a r e n t l y o u t -  spoke h e r husband so t h a t t h e r e was not a b a l a n c e i n t h e " s o c i a l p a r t n e r s h i p " . Mr. G. was w o r k i n g s t e a d i l y , b u t was u s i n g much of h i s income f o r d r i n k i n g so t h a t he was n o t r e a l l y a good p r o v i d e r .  M r s . G. q u i t h e r own j o b  i n o r d e r t o "encourage Mr. G. t o be t h e p r o v i d e r " . M r s . G. seemed t o be adequate as a homemaker i n t h e a r e a o f c o o k i n g and k e e p i n g house. There x^ras no c o m p l a i n t made about t h e s e x u a l r e l a t i o n s h i p and i t was assumed t h a t t h e r e was a q u i t e s a t i s f a c t o r y r e l a t i o n s h i p h e r e .  Schedule G^ -Mr. G. Age 43 years - married 2 years.  Occ: Millworker Religion: A. C. C.  ; i j j 1  :  i |  (Patient)  Source of Stress  Value Threatened  Duration of Stress  Response to Stress  Effect on Reciprocal Relationship of Husband and Wife  Early rejection of parents, lack of mothering from foster mother. Lack of male figure to identify xri.th during childhood.  Need for affection and consistent mothering. Need for ego ideal , so that oedipal conf l i c t could be resolved.  During early childhood.  Continuing demand for affection and for dependent relationships, heavy drinking as a substitute for dependent relationship,, failure to develop strong ego or super ego controls.  Dependency on wife; wife could not supply this need to his satisfaction. Also husband could not supply strong support for wife.  Failure to get mothering from his wife.  Need for mothering and for dependent relationship.  Two years.  Seeking satisfaction i n heavier drinking; some anger toward wife.  person with whom the child identifies and whom he emulates.  Arguing and conflict; ; imminent disintegration of the marriage.  Schedule G - Mrs. G. 2  Occ;: Housewife Religion: A. C. C,  Source of Stress  Failure to have childhood needs for loving and dependency met. ,- Gross pathology in the family, especially i n j father. i  Failure to get protection and support from husband. Danger of the marriage breaking up.  Age 47 years - married 2 years.  (Relative of Patient)  Value Threatened  Duration of Stress  Response to Stress  Effect on Reciprocal J Relationship of Husband and Wife  Need for affection and dependency. Need for consistent relationship with strong parent figures.  Since early childhood.  Continuing demand for dependency; long history of seducing men older than herself (father figures) or younger than herself (son figures).  Dependency on husband which he could not meet because of his own dependency needs and his inadequate personality.  1 Need for dependency Two years. from strong male figure.  Withdrawal into herself; some anger toward her husband.  Arguing and conflict; growing emotional separation; danger o f breakup of the marriage.  :  Need to have success i n at least the third marriage.  Six months. Desire to get help; convincing husband to seek help with his problem as well.  Mutual decision to get help with the marriage problem.  - 64 -  Case G - Assessment i n Terms of Stress Concepts Mr. G., a part Indian, had suffered the loss of his mother through death when he was three years old and was then brought up by his aunt who had a large family of her own.  He received l i t t l e love i n this home and was forced  to compete with the other children for whatever affection was available.  The  early loss of his parents and the lack of mothering from his foster mother was a source of stress for Mr. G. as i t threatened his need for affection and for consistent mothering.  His long-term response to the resulting stresses was a  continued demand for affection and for dependent relationships which he sought to satisfy i n his relationship with his wife. Also during his oedipal phase of development, he lacked a male figure to identify with, thus threatening his need for a resolution of the oedipal conflict.  His search for an ego ideal being frustrated, he responded by failing  to develop a strong ego and sufficiently strong super-ego controls. In the marriage, these long-term responses were seen in his dependent relationship with his wife and his inability to supply strong support for his dependent wife.  They were also seen in his violent temper outbursts toward his  wife, which showed l i t t l e control over emotions. Because his wife was a very dependent person herself and unable to give any degree of support, Mr. G. failed to get satisfying protection and mothering from her.  This then became a source of stress for Mr. G. as he valued  such a dependent relationship. t e r i s t i c with him:  He responded to this i n two ways that were charac-  more violent temper outbursts toward his wife, and escape to  heavier drinking for a substitute dependent relationship.  Conflict and argument  soon developed and the marriage, after two years, was at the point of breaking up. Mrs. G. also had suffered a very stressful period i n her early  childhood in that there was a failure in having her primary needs for loving and for dependency met by her parents.  Her father had been known as the  "town bum" and provided l i t t l e strength for his family. Her mother had provided a poor ego ideal.  Because of the stress of the poor relationship with her  parents, Mrs. G. responded throughout her l i f e by demanding dependent relationships with others - particularly in sexual contacts. Older men with whom she had contact she saw as protecting father figures whereas she projected her dependency needs on the younger men with whom she had contact and saw them as son figures.  Although she chose this way to meet her needs for intense intimate  personal affection, she always f e l t that she-was being exploited and rejected. In Mrs. G.'s marriage to Mr. G., she sought to have her dependency needs met i n what to her was a more acceptable way than in extra-marital relationships.  She hoped that her husband would not reject her as the other men  had done. I t turned out, however, that because of his own needs and his own rather inadequate personality, he could not give her what she required. The failure to get protection and support from her husband then became a source of stress i t s e l f .  To this she responded, f i r s t , by withdrawal  into herself and with considerablej ambivalence about her husband.  She also  suffered a great deal of anxiety as she saw that the marriage i t s e l f was threatened. Because Mrs. G. had already been married twice before thi-s, the danger of the third marriage breaking up became a source of stress.  She responded to  this by constructively looking for possible ways of getting help with the marriage.  She convinced her husband of this as well and together they made  arrangements to be seen at the Clinic.  - 66 -  Cage fl - Summary Mrs. H. was referred to the Clinic after a period of private psychiatric treatment and an extended contact with a caseworker at a Family Service Agency. She talked interminably about her physical complaints although the presenting . symptoms that had precipitated the referral were exhaustion, indecision, feelings of hopelessness and extreme inner tension. It was f e l t by the Clinic staff that Mrs. H.'s fatigue and chronic illnesses, as well as her inability to assume the responsibility of caring for her home and family appeared to be arising out of the total lack of emotional satisfaction which.she was receiving i n this environment. Mr. H. appears to be very unsure of himself and seems to be a dependent, somewhat immature person who has become anxious about his wife's overt rejection.of himself and the older daughter.  He tends to attribute this beha-  vior to "mental illness" on his wife's part and sees l i t t l e that he may be doing to incur this reaction.  Mr. H. appears to be very dependent upon his mother  and feels that his wife i s very resentful of his mother and can see no basis for her feeling this way. Mr. H. seems to have l i t t l e awareness of his wife's problem or of the reasons for the difficulty i n the marriage and although he expresses eagerly his desire to become involved i n the treatment, there was some doubt about his sincerity i n this. For some three or four years before the assessment, these marriage partners had been completely isolated from each other insofar as sexual or emotional satisfactions or sharing of any type was concerned.  This appeared to  have been precipitated by several years of living under extreme financial hardships, inadequate housing and by the overly dependent relationship which  - 67 -  the husband had with his mother i n ttfhich the wife was excluded.  At the time  of referral, there i s also developing a rather extensive, competitive conflict between the seventeen-year old daughter and Mrs. H., and an active oedipal situation i s continuing between Mr. H. and this daughter.  Mrs. H. i s outrightly  rejecting this g i r l , but i s overprotective and overattentive toward the younger daughter. Mr. and Mrs. H. have very limited social contacts and provide no social satisfaction for each other.  Just before the assessment, they were  sleeping separately and had no sexual relations.  However, when they moved to  a new house, i t was necessary for them to use the same bedroom, but this created so much anxiety,for Mr. H. that she asked her older daughter to sleep in the same bedroom with the parents. Mr. H. seems to be a good provider but Mrs. H., because of her psychiatric symptoms, i s having difficulty  with  her role as homemaker.  Schedule Occ: Housewife Religion: Protestant Source of Stress  Value Threatened  - Mrs. H. Age 48 years, married 19 years.  Duration of Stress  Father's r i g i d , | Secure, consistent harsh control during home environment; early years; illness health i n family. and death of mother;' illness of youngest sister; remarriage of father.  Since early childhood.,  Unhappy marital interaction.  Mutual satisfaction i n the marriage.  Move of family to coast from prairies. Dislocation from familiar surroundings and from social environment.  Need for consistent social environment as a support.  Progres- j sively since beginning of marriage. Eight years.  Close relationship between daughter and husband.  Wishes, i n her ambivalence, to have husband for herself.  Three years.  (Patient)  Response to Stress  Loneliness and withdrawal from other people during childhood; leaving home at early age; i n I ability to form close attachments with other people; passive anger toward authority figures. Withdrawal from husband; strain and i r r i t a b i l i t y ; projects blame on husband.  Effect on Reciprocal Relationship of Husband and Wife Emotional distance between husband and wife as neither could form close attachments; ambivalent feelings on part of wife toward , husband with a great deal of passive anger toward him. Breakdown of communication; no sharing of interests or activities•  Withdrawal from a l l social l i f e ; intense loheliness; increased need for the support of husband, but at the same time increased anger toward husband because the new need for closeness threatened her.  Increase i n marital conflict; sexual relations stop. This drives husband into closer relationship with older adolescent daughter.  Identifies daughter with husband and dislikes both intensely. Turns to second daughter to enlist support for herself makes daughter dependent on herself. Psychiatric symptoms i n form of acts of aggression in the home. Seeks help i n a self defeating way.  Tremendous amount of mutual anger. Mutual agreement on getting help.  Schedule H" - Mr- H. 2  Occ: Salesman Religion: Protestant  Age 43 years, married 19 years.  Source of Stress  Value Threatened  Duration of Stress  Response to Stress  Controlling and possessive mother.  Opportunity to become independent and mature.  Since childhood into the. marriage.  Enjoyed dependent relationship with mother; failed to become mature.  _a  Wife's passive anger toward him.  i Wish to have wife ; express her feelings and in this way to get j r i d of them.  Wife's rejection of him physically a l emotionally.  Acceptance by wife Eight and close relation- years. | ship with her.  Wife's psychiatric symptoms. T  Desire for healthy wife.  Since early A rather deep concern in marriage. about this and withdrawal : from her to defend himself from her feelings.  Three years.  Rejection of wife and turning to adolescent daughter for emotional -satisfaction.  (Relative of Patient)  Effect on Reciprocal Relationship of Husband and Wife Mr. H*s close relationship with his mother caused resentment on part of h i s wife. Mr. H. could . see no reason for this. Growing distance between husband and wife; breakdown in communication. Marital conflict; increasing anger.  Wish to dissolve marriage; A separate existence in the same house. realization that professional help i s needed.  - 70 -  Case H - Assessment in Terms of Stress Concepts Mrs. H. described her childhood and adolescence as quite distressing. Her father was a very strict person who controlled Mrs. H.'s social l i f e to the point where she was permitted almost no social l i f e outside of the family. She was very lonely as a child, consequently. Her mother was i l l much of the time which required her to be i n bed during Mrs. H.'s early adolescence. The mother died when Mrs. H. was fourteen years old. The youngest of her two sisters was spastic and retarded.  The father remarried six months after the  mother's death and this created a great deal of resentment on the part of Mrs. H. who l e f t home shortly after. This unsettled early l i f e seemed to threaten Mr. H.'s need for security, for a consistent, accepting home environment and for health in the family.  Her  response, partly determined by her father's restrictions was to withdraw from other people and from d i f f i c u l t situations.  She responded throughout her l i f e  by withdrawing from close attachments to people and with passive anger toward authority figures of any kind. There was a marked effect of this life-long pattern on the marriage relationship.  There was an emotional distance between the partners as neither  of them could form really close attachments without feeling threatened. Mrs. H. had strong ambivalent feelings toward her husband with a great deal of passive anger toward him. The unhappy marital interaction then became a source of stress, threatening Mrs. H.'s need for a mutually satisfying marriage relationship.  As  this had begun near the beginning of the marriage, she had responded progressively by greater withdrawal from her husband.  She f e l t under strain and was irritable,  and projected blame for the marriage difficulty on to her husband.  The result  - 71 -  of this was a breakdoxm i n communications, a failure i n sharing interests and activities. The family's move from the prairies to the West Coast was a particul a r l y distressing event for Mrs. H. as i t involved a dislocation from familiar surroundings and from a familiar social environment even though this was very restricted.  The move threatened her need for familiar environmental supports  and responded, characteristically, by withdrawing from a l l social l i f e and with intense loneliness.  She f e l t an increased need for support from her husband,  but at" the same time, this new need for closeness was threatening to her and she.became even more angry with him. The result of this on the marriage was increased marital conflict, and an end to sexual relations.  This drove the husband into a closer relation-  ship with his older adolescent daughter. Although Mrs. H. had, possibly unconsciously, been fostering-a closer relationship between husband and daughter, the alliance proved a source of stress for her.  Her wish, even i n her ambivalence to have the husband for  herself was threatened by this relationship.  Her response to this was that  she identified her daughter with her husband and disliked both intensely.  She  then turned to her younger daughter to enlist her support f o r herself by making the child dependent on her.  Besides, Mrs. H.'s psychiatric symptoms were inten-  sified by the family situation to the point where she became physically aggressive in the home. At this point' she recognized her need for help, went about looking for.help but i n a self-defeating way so that she moved from one treatment person to another. The marital relationship by this time was so disturbed that both husband and wife saw that help was required and both agreed to get this although  - 72 -  both f e l t very threatened by this and eventually withdrew from treatment. Mr. H.'s background was only very briefly described in the record. He did have a controlling and possessive mother, which threatened Mr. H.'s need for becoming independent and mature. His long-term response was to remain a dependent and f a i r l y immature person and to enjoy the relationship with his mother even into the marriage. There were obvious repercussions on the marriage relationship i n that M . rs  H. resented her husband's close relationship with his mother, although  he could see no reason for this resentment. Mr. H.'s second significant source of stress i n the marriage was his wife's passive anger toward him.  This threatened his wish to have his wife  express -her feelings toward him and in this way to get r i d of them. He responded to this d i f f i c u l t y , ever since his marriage, by deep concern about i t and by withdrawal from his wife i n order to defend himself from her feelings.  This  resulted i n a growing distance between husband and wife and eventually i n a complete breakdown of communication between them.' His wife's rejection of him, both^emotionally and physically, then became a source of stress for Mr. H.  His need for acceptance by his wife and  for a close relationship with her were threatened. He eventually responded by rejecting his wife and by turning to his older adolescent daughter for some emotional satisfaction and for support against his wife's attack. At this point there was a good deal of conflict and increasing feelings of anger between husband and wife. Finally, Mrs. H.'s psychiatric symptoms became a source of stress, threatening his desire for a healthy wife. His response was eventually to dissolve the marriage, but also the realization that some form of professional  - 73 -  help was needed. At this point, Mr. and Mrs. H. were living, for a l l practical purposes, a separate existence in the same house.  This concludes the presentation of case material, and assessment of the marriages i n terms of the concepts of stress.  I t w i l l now be necessary  to draw together some of the findings of this research and to discuss any implications of these for casework.  The f i n a l chapter w i l l deal with this.  CHAPTER IV  IMPLICATIONS OF THIS STUDY FOR THE ASSESSMENT OF MARITAL CONFLICT CASES  The Purpose of This Study This thesis i s concerned with attempting to apply the concepts of soc i a l role and stress to the assessment of marital conflict.  The purpose i s to  assess the usefulness of these concepts for improving the social worker's understanding of the interaction process i n disturbed marriages. This chapter w i l l review some of the major limitations of the present study.  This w i l l be followed by a presentation of the findings.  w i l l then be discussed more f u l l y i n terms of role and stress concepts.  These There  - w i l l be mention made of two issues which seem to come out of this study which require further research. Finally, some implications of this study for the assessment of marital conflict cases w i l l be suggested.  The Limitations of This Study Some of the limitations of the research methods used i n this study were discussed earlier.  We shall now look at some of the limitations posed  by the material used for the present analysis. The clients assessed i n this study did not simply suffer from a marriage conflict problem.  In each case, one of the partners was psychiatrically  diagnosed as suffering from some form of mental illness.  Consequently, the  case recordings at the Clinic dealt not only with the marital interaction, a l though this was always considered as a part of the problem. They were concerned to a large degree with the development of the psychiatric problem.  This made  the assessment of the marital interaction alone, as required for this study,  -  75 -  more d i f f i c u l t as i t meant that this material had to be gleaned out of the recordings that were largely focused on the presenting symptoms of mental illness.  In summary, then, where the purpose of this study was to assess the  interaction of marriage partners, a major emphasis of the recordings was on the symptoms of mental illness. The second major difficulty was in the area of the theoretical o r i entation of the Clinic from which the cases were taken. While this study attempted to apply the interactional approach of role and stress theories, the Clinic was psychoanalytically oriented.  Tlie case recordings frequently pre-  sented material that would be significant from a psychoanalytic point of view but did not seem to present sufficient information that would have appeared significant from the interactional point of view.  This required the present  writer to make rather liberal interpretation of statements found in the records for the purpose of this analysis. This was most evident in the category "effect of the stress on the reciprocal relationship of husband and x<rife".  Since this  category was the most important one for the purpose of this study, there was an obvious limitation on the information available about this. These problems raise a significant issue.  The psychoanalytic orien-  tation and the interaction orientation are quite different i n their points of emphasis. The question i s :  i s i t possible to use recordings which show a  psychoanalytic orientation for research purposes where the usefulness of role and stress theories are being tested?  I t would appear, on the basis of this  limited study, that to test the usefulness of role and stress theories, one would have to use this orientation in the actual assessment of the clients. Then an analysis of the records made from this could be useful for purposes of such a research project.  - 76 -  Regarding the use of the theoretical orientations at the Clinic where this analysis was made, i t i s possible that a psychoanalytic orientation i s necessary for the social workers i n order to provide the psychiatrist with information that w i l l be meaningful to him in making a diagnosis.  We must re-  member, again, that the purpose of the Clinic i s to treat patients suffering from mental illness and that the professionals directly responsible for their treatment are psychoanalytically oriented psychiatrists.  It may therefore be  necessary for the social workers at the Clinic to maintain their orientation to a degree. It should also be said that efforts are being made at the Clinic to introduce role and stress concepts to the social work staff.  The cases used  for analysis in this study were a l l closed before this new emphasis in staff training began. It may well be that newer records would be more oriented in the direction of role and stress concepts and that this emphasis would provide a fuller understanding of marriage conflict.  This could only be tested out by  further research.  The Findings of This Study The findings w i l l f i r s t be presented in terms of broad generalizations and then a discussion of these w i l l follow.  This discussion w i l l take  into consideration the limitations of methodology and of record material as discussed previously.  The findings are in no way assumed to be conclusive because  of these limitations.  The writer only wishes to point out some possibilities  and suggest areas needing further research. Briefly, the major generalizations coming out of this study are these:  - 77 -  (1)  The use of the concept of r e c i p r o c a l r o l e functioning i n  marriage made i t possible to break the c l i e n t s ' t o t a l s o c i a l behaviour down and e x t r a c t the manageable u n i t s of husband and wife r o l e s . (2)  The use of s t r e s s concepts revealed a pattern of s t r e s s  response to s t r e s s that began i n the e a r l y experiences of childhood  and  and  ex-  tended i n t o the marriage r e l a t i o n s h i p . (3)  There was  a discernable r e l a t i o n s h i p between the source of  stress and the development of c o n f l i c t i n the marriages. (4)  The nature of the stress f a c t o r s appeared to c o l o r the q u a l i t y  of the i n t e r a c t i o n between the marriage partners. (5)  There appeared to be a progressive b u i l d i n g up of s t r e s s f a c -  t o r s i n a discernable p a t t e r n .  .  The Concept pf Role I t was  stated at the outset t h a t , i n analysing the case records,  we  would be l i m i t i n g the r o l e theory concepts to those dealing with r e c i p r o c a l r e l a t i o n s h i p s and to the impairment i n the s p e c i f i c r o l e s involved i n those relationships.  For the purposes of t h i s study, then, our concern was  with the husband and wife r o l e s i n each of the eight cases.  only  Performance i n  other r o l e s was taken i n t o consideration only where t h i s affected the husband or wife r o l e d i r e c t l y .  This was  seen i n Case H . , f o r example, where the hus-  band-daughter r o l e s played a s i g n i f i c a n t part i n the marriage c o n f l i c t .  Also,  the r e c u r r i n g theme, of childhood d e p r i v a t i o n x^hich a f f e c t e d the present husband and wife r o l e s would i l l u s t r a t e t h i s . I t would seem from the case analyses that r o l e concepts have provided a convenient way  of breaking the t o t a l s o c i a l behaviour of the marriage partners  - 78  -  into more manageable units so that the specific roles of husband and wife could be singled out for social work assessment.  This seemed particularly  useful in the cases presented here because, in a l l cases, the marital d i f f i culty was recognized by the clients themselves and by the professional staff at the Clinic as being the chief area of complaint, next to the actual symptoms of mental illness presented by the clients.  But this is not without i t s weak-  nesses. This analysis has isolated one area of the client's social functioning and has excluded a l l other roles that were not seen as directly affecting the marital role. The question can be raised whether, in fact, this i s a legitimate way of assessing these individuals since they obviously were functioning in other roles as well. We might keep in mind again, however, that the impairment in social functioning was recognized to be principally in the husband and wife roles and that impairment did not necessarily show up evenly in a l l social roles.  The role of breadwinner, in the case of each of the husbands assessed,  was not impaired appreciably, for example, and each was providing a comfortable living for the family. Although we would concede, then, that this -analysis has not given a complete picture of the client's social functioning and therefore i s limited in scope, i t has s t i l l highlighted the most severely impaired roles and has assessed the area that has been recognized as the main problem by the clients. We should also keep in mind that the purpose of this analysis was  _  to apply the concepts of role and stress to the assessment of marital interaction, and to assess the usefulness of these concepts for such an analysis. purpose was not to assess total social functioning of these clients.  The  - 79 -  The Concept of Stress A number of d i f f i c u l t i e s were recognized i n applying this concept to the cases presented here.  I t has already been stated that the case records  were not written i n terms of source of stress, value threatened, response to stress, and effect of the stress on the reciprocal relationship of husband and wife.  In some cases, i t was necessary, therefore, to make rather arbitrary  decisions.  This was particularly evident when tracing a source of stress back  to early l i f e experiences.  It was not always clear what the long-term response  was to this stress in childhood.  The f i n a l category, "effect on the reciprocal  relationship of husband and wife", required that the writer interpret statements made by the clients or statements made by the worker who recorded the interviews . Because of these d i f f i c u l t i e s , the possibility of error i n the findings i s increased.  In spite of this, however, some general statements about the  findings can be made. F i r s t , there appeared to be a discernable relationship between individual clients' sources of stress and the clients' response to this, and the development of conflict within the marriages. It became quite evident in analysing the case recordings, that the use of the concepts of stress laid down in the Curriculum Study , together with the category "effect of stress on the reciprocal relationship of husband and wife", provided a useful means of tracing the cause of marital conflict back to the factors within the individuals involved in the marriage.  Boehm, ¥., Curriculum Study. Vol. X.  -  80  -  Because t h i s appears i n a l l of to include  o n l y a few (1)  the  I n the  case of Mrs.  B.,  the  a p p a r e n t d o m i n a t i o n by  c l i e n t ' s , m a r r i a g e seemed t o b e  and  B.  d e v e l o p i n g a low  a need f o r dependent r e l a t i o n s h i p s .  h u s b a n d and  her  helpful  examples of i t .  c o n t r o l l i n g m o t h e r seemed t o r e s u l t i n M r s . w o r t h and  case a n a l y s e s , i t w i l l be  reflected  The  i n her  effect  a  stern,  sense of  o f t h i s on  the  dependent r e l a t i o n s h i p  husband's o v e r p r o t e c t i o n of her.  self-  on  Both recognized t h i s  her  situation  b o t h seemed u n h a p p y w i t h i t . T h u s t h e r e seemed a d i r e c t r e l a t i o n s h i p b e t w e e n t h e  source of  stress (2)  and  the  I n the  behaviour i n that a p p a r e n t l y by  she  marital  wife's original  interaction.  c a s e o f Mr.  D.,  continued to  the  see  source of  her  stress  former husband.  f e e l i n g a n g e r t o w a r d h i s w i f e and  lay in his Mr.  D.  wife's  responded  seemingly created a mutual  t e n s i o n r e s p o n s e , e m o t i o n a l d i s t a n c e b e t w e e n h u s b a n d and  w i f e and  unsatisfactory  sexual relations. If and  the  t h i s o b s e r v a t i o n of  response to stress  would appear t h a t way will  of  the  and  r e l a t i o n s h i p between the  q u e n t l y show a p a t t e r n  stress  interaction.  have, i n f a c t , provided a  I t may  a n a l y s e s of t h e of s t r e s s  experiences of  life  e f f e c t on  relationship.  that  and  c h i l d h o o d of Mrs.  father  figure.  To  A.  a l s o be  and  that  course of  response to stress  I n C a s e A.,  this  stress  then i t helpful  observation  treatment.  cases presented here appeared to  extended i n t o the  fre-  t h a t began i n the  marriage r e l a t i o n s h i p , having a the  apparently resulted  t h i s her  source of  m a r r i a g e c o n f l i c t i s a v a l i d one,  h e l p t o p r o v i d e some d i r e c t i o n i n p l a n n i n g t h e S e c o n d l y , the  the  the  concepts of  assessing marital  the  loss i n her  of parental seeing her  h u s b a n d seemed t o r e s p o n d b y  figures  direct  during  husband as  t r e a t i n g her  early  like  a a  - 81 child.  Mrs. B. appeared to be dominated by her r i g i d , controlling mother  and this seemed to result eventually in Mrs. B.'s excessive dependence on her husband. He, i n turn, seemed to.respond by overprotecting her although both were unhappy with the relationship.  Similarly, in Mrs. C's case, the  separation from her parents i n early childhood and the general instability of the social situation in early l i f e appeared to lead to a need for a dependent relationship with a strong successful male. In Case E., the low sense of self-worth which appeared to result from parental rejection seemed to lead Mrs. E. into marriage with a man who, she f e l t , was beneath her and with whom she could compare herself favorably.  A dependent relationship in response to  childhood rejection seemed apparent.in the cases of Mrs. F. and Mr. and Mrs. G. Mrs. H. had apparently learned, through early parental rejection, to withdraw from close relationships with people and this apparently made her unable to form a close attachment with her husband. Although not a l l case records included reports on the marriage partners' early l i f e experiences, there were enough to suggest that early l i f e experiences may have had an affect on the marriage interaction.  A thorough  examination of this relationship could hardly be given-on the basis of this brief presentation, nor was this i t s main focus, but some possibilities do suggest themselves. Any person, to make the many compromises and adjustments necessary for l i f e in a complex society must have achieved an adequate level of maturity; that i s , a point at which he can control his needs and impulses; where he can establish satisfying relationships with people; where he can recognize the strength of his own and other people's feelings; where he can see the difference between the actual nature of objects and his fantasies, and where he can meet .  - 82 -  varying l i f e situations with appropriate responses.  Because of the intimate  closeness of the relationship of marriage partners, adjustment of a high order i s necessary, and a f a i r l y high level of maturity i s required for both partners.  In the cases presented i n this paper, there seems to be a conside-  rable degree of what might be termed immature behaviour on the part of the marriage partners. This i s seen particularly in the apparent need of a number of the wives and at least one of the husbands to apparently seek a highly dependent relationship with the spouse.  This i s seen in the case of Mrs. A.,  Mrs. B., Mrs. C., Mrs. F., Mr. G. and Mrs. G.  In each case, there seemed to  be a failure i n providing equal and mutually satisfying emotional support for the other spouse, but a great need to receive support.  In-each of the cases  mentioned, however, there was a history of early deprivation and a failure to have childhood dependency needs met.  It i s possible that this prevented the  client from developing into an independent adult.  This seemed to be shown by  continuing, throughout l i f e , to seek satisfaction for these unmet needs. Consequently each was unable to achieve a mature relationship with the spouse to whom he looked for" the support he failed to get as a child. Thirdly, it'would appear, from the cases analysed, that the nature of the. stress factors color the quality of the interaction between the marriage partners.  Several-illustrations could be cited here. • The rejection by parents and the search in marriage for a substitute  parent has been mentioned i n other connections but i s most applicable here as \tfell-.  In several of the cases, the apparent parental rejection seemed to pro-  duce a very similar response - dependency on the spouse.  In this way, the  nature of the stress factor seems to have produced this specific form of relationship i n the marriage.  - 83 -  In several cases where d i s s a t i s f a c t i o n with the sexual r e l a t i o n s h i p was considered a source of stress, there seemed a d i r e c t connection between t h i s f r u s t r a t i o n and an increasing anger between the marriage partners. seemed to be shown i n the case of Mr. and Mrs. B., and Mr. and Mrs. D.  This In the  case of Mr. and Mrs. H., the unsatisfactory sexual r e l a t i o n s h i p seemed to intens i f y the m a r i t a l c o n f l i c t and led to further complications. ~ In Case C., the apparent breakdown of communication between Mr.  and  Mrs. C. to the point where neither one could express f e e l i n g s toward the other seemed to r e s u l t i n increasing anger b u i l d i n g up i n each partner.  This mutual  unexpressed anger became a dominant theme i n the marriage c o n f l i c t and eventually threatened the marriage i t s e l f .  Here again, the stress factor; i . e . , the ina-  b i l i t y to express feelings of anger, apparently colored the q u a l i t y of the i n t e r action between the partners. A fourth p o s s i b i l i t y xtfhich presents i t s e l f i n the analysis of the cases i s the seemingly progressive b u i l d i n g up of stress factors i n a f a i r l y clear pattern.  Here again, enough information i s not always available i n a l l  the case recordings, but the pattern i s shown i n some of the schedules  presented  earlier. In the case of Mrs. A., f o r example, the pattern seems to take the folloxtfing form: (1) childhood.  The f i r s t source of stress was  the loss of her parents during  Consequently she continued to look for dependent r e l a t i o n s h i p s with  other people including her husband, who was  not w i l l i n g to give her complete  satisfaction in this. (2)  Her husband's f a i l u r e to meet her dependency needs became a  stress factor which caused Mrs. A. to turn outside of the marriage f o r t h i s  - m  satisfaction. (3)  -  She chose h e r husband's f r i e n d f o r t h i s  purpose.  T h i s r e l a t i o n s h i p then became a source o f s t r e s s as i t r a i s e d  g u i l t f e e l i n g s i n Mrs. A.  T h i s r e l a t i o n s h i p , t o o , when i t was d i s c o v e r e d by  Mr. A., p r e c i p i t a t e d t h e e x p r e s s i o n o f anger  on the p a r t o f both p a r t n e r s and  the marriage was t h r e a t e n e d w i t h b r e a k i n g up. A s i m i l a r p a t t e r n seems e v i d e n t i n t h e case of Mrs. B. (1) childhood.  Mrs. B. seemed dominated by a s t e r n , c o n t r o l l i n g mother d u r i n g  T h i s l e d t o c o n t i n u e d need f o r dependent r e l a t i o n s h i p s which found  e x p r e s s i o n i n t h e r e l a t i o n s h i p w i t h h e r husband. (2)  Mrs. B. r e a l i z e d t h a t t h i s was not t h e accepted r o l e o f a w i f e ,  however, and t h i s became a s o u r c e o f s t r e s s .  I t caused g u i l t f e e l i n g s and an  i n t e n s i f i e d need f o r p r o t e c t i o n which e v e n t u a l l y i m p a i r e d h e r s e x u a l r e s p o n s i v e ness. (3)  The s e x u a l f r u s t r a t i o n t h e n became a s o u r c e of s t r e s s l e a d i n g t o  i n c r e a s e d anger toward  h e r husband and complete  d i s s a t i s f a c t i o n w i t h t h e mar-  riage. T h i s b u i l d i n g up o f s t r e s s , one f a c t o r upon a n o t h e r , a l s o seems t o be shown i n t h e case o f Mr. and Mrs. D., M r s . E . , and Mr. and Mrs. G.  Although  t h e p a t t e r n may have been p r e s e n t i n o t h e r c a s e s as w e l l , t h e r e was n o t s u f f i c i e n t m a t e r i a l i n t h e case r e c o r d s t o see t h i s p a t t e r n . B e f o r e c o n c l u d i n g t h i s paper w i t h a b r i e f d i s c u s s i o n o f t h e i m p l i c a t i o n s of t h e s e f i n d i n g s f o r casework assessment of m a r i t a l c o n f l i c t c a s e s , we might r a i s e two f u r t h e r i s s u e s which became important f a c t o r s i n t h i s These d i d not f i t i n t o t h e a c t u a l purposes adequately d e a l t with.  study.  of t h e study and so c o u l d n o t be  I t seems n e c e s s a r y , however, t o r a i s e t h e i s s u e s and  suggest them as f u r t h e r a r e a s i n which r e s e a r c h i s n e c e s s a r y .  - 85 -  Role Theory and Psychoanalytic Theory Role and stress theories are s t i l l in very early stages of formulation and testing in terms of their application to social work practice.  A  growing amount of literature i s becoming available, however, describing beginning attempts to relate role theory to practice*  on a theoretical level.  At the same time, we must keep in mind that social workers have, for a longtime leaned heavily on psychoanalytic theory to provide a frame of reference i n which to work. The question that frequently presents i t s e l f i s what relation the new theory holds to the more traditional social work approach.  Although  the purpose of this thesis was not to explore this question, the case analyses seem to have suggested that some relationship does exist. It has been stated earlier that the early l i f e experience of several of the persons assessed here had a significant part to play in relationships with their respective spouses in adulthood.  I t must be kept in mind that this  conclusion was arrived at by the use of role and stress concepts.  It i s sig-  nificant that one of the principles of psychoanalysis i s that the wishes and responses of adult l i f e "are important only as they a l l y themselves with those  2 of childhood."  Psychoanalytic theory states that adult behaviour i s s i g n i f i -  cantly controlled by childhood experiences and that adult wishes are,' i n fact, reflections of early childhood wishes.  The analysis of case records i n terms  of role and stress seems to bear out this psychoanalytic assumption.  I t would  appear from the analysis, however, that role and stress theories take one For a detailed review of such literature, see: Olds, Victoria, "Role Theory and Casework, A Review of the Literature", Social Casework, Vol. XLIII, No. 1, January, 1962.  2  Kinsie, Leland E.» and Campbell, R. J., Psychiatric Dictionary, Third Edition, quoting Ernest Jones' delineation of the seven major principles of Freud's psychology. Oxford Press, i960, p. 590.  - 86 -  further step by seeing not only early l i f e experiences but also the stress factors and impairment of roles throughout l i f e as significant for purposes of assessment. It would appear, then, that role theory does not, as sometimes feared, discard psychoanalytic theory but actually makes a much needed addition to i t in that i t emphasises the meaning of interaction i n the various social relationships in which any given person has moved and i s currently moving. Boehm emphasises the relationship between psychoanalytic theory and role theory: Social functioning thus i s seen as derivative behavior resulting from ego functioning. Social functioning can be conceived as the sum of the individual's activities i n interaction with other individuals and situations i n the environment. Each interaction reflects somatic and psychic factors on the one hand, and social factors on the other. Hence, ego functioning can be considered to be one aspect of social functioning. Somatic functioning would be another. But since both types of functioning are interrelated with the social and other aspects of the environment, a person's social functioning can be understood only by assessing the social, somatic, and psychological factors and their combinations which determine the quality of social functioning, 1  This interrelatedness of psychoanalytic theory and social role theory has also been demonstrated in a recent thesis by Constance M . Hawley. She concludes: Psychoanalytic theory provided a means for a better understanding of the dynamics of the individual - a necessary step in this development .... The tremendous contribution of the social role theory is that i t leads from an understanding of individual dynamics to an understanding of family group and eventually community dynamics. While i t utilizes psychoanalytic and ego psychology theories, i t has integrated them with sociological theories, or i n other words, has put our understanding of individual dynamics i n a social context. Thus i s provided a better balanced perspective of man in relation to society. 1  2  Boehm, W,, Curriculum Study, Vol. X, p. 94.  . - .  .  .  Hawley, Constance M., Role. Stress and Social Work Practice. Master of Social Work Thesis, University of British Columbia, 1961, p. 163.  - 8? It would seem, then, that role and stress theory can be profitably used i n collaboration with psychoanalytic theory and that this can give the social worker.an enlarged understanding of the client's total functioning. Obviously, the findings of this study only point out the possibility of this relationship, but i t does indicate that there i s a need for further research into this area.  Marriage Conflict and Mental Illness The clients referred to the Clinic in which this study was done, were referred because they presented symptoms of mental illness.  In a l l  cases, the symptoms were not seen, for the purpose of this study, as means of diagnosing the form of illness, but were seen simply as part of the behavior pattern of the clients.  From the case recordings, however, i t was recognized  that there was a,close relationship between marriage conflict and mental i l l ness.  In some cases, the marriage problem seemed to be a precipitating fac-  tor i n bringing about symptoms of mental illness.  In "Case F", however, the  marriage seemed to have been at least tolerable until the psychiatric symptoms seemed to upset the delicate balance of the marriage and cause i t s breakdown. Again, the relationship between mental illness and marriage conflict was not the problem under consideration here, and we can only suggest that there i s a relationship.  Just what this connection might be i s a further area  of research that would seem to require considerable attention.  Implications for Assessment of Marital Conflict Cases We have seen that a recognizable-pattern i n the source of stress  -  88  -  and response to this stress within the marriage relationship became evident in a number of the cases assessed here.  This pattern may have been apparent  to the social workers making the assessment originally. not  mention i t directly i n the case recordings.  I f i t was, they did  I f i t was not apparent, then  i t would seem that the method of analysis used here could contribute to the understanding both of the individuals involved in the marriage and of the marriage interaction.  The use of this theory would help the worker i n assessing  a marriage conflict case to make his assessment on two levels:  f i r s t , he would  gain some understanding of the individuals involved, their areas of vulnerab i l i t y and their characteristic modes of response to stress.  Then, with this  knowledge in mind, he could assess more accurately the pattern of the interpersonal relationship as i t existed between the marriage partners by seeing how each partner's characteristic patterns of response affected the interaction process. Brangwin calls this two-level approach i n assessment "psychosocial diagnosis" and says of i t : A dynamic study process which has come to be known in casework as psychosocial diagnosis, i s essential i f the nature of the disturbance i s to be comprehended and sound measures initiated for dealing with i t . It i s i n this "psychosocial" approach that social work has a significant contribution to make in the assessment of marriage conflict cases, i t would appear from this study. the Curriculum Study  2  The concepts of role and stress as outlined i n  seem to add to the social worker's knowledge by  Brangwin, L. C., "Marriage Counseling - the Viewpoint of the Caseworker", Social Casework. Vol. XXXVT, No. 4, April, 1955. p. 157. 2  Boehm, op. c i t .  -  89  -  providing a framework for analysis that covers both an assessment of the individual marriage partners and the marital interaction i t s e l f .  - 90 -  APPENDIX  "A"  PSYCHIATRIST'S ASSESSMENT NOTE - CASE  T h i s p a t i e n t was  A.  1  seen on r e f e r r a l o f Dr. F., F r i d a y , January 9»  F o r t h r e e and a h a l f days around Christmas  she was  admitted t o  19—•  General 2  H o s p i t a l under Dr. J . w i t h a t e n t a t i v e d i a g n o s i s o f a n o r e x i a n e r v o s a .  Her  l a c k o f a p p e t i t e has been p r e c i p i t a t e d by her c o n f e s s i n g t o her husband t h a t a f a m i l y male f r i e n d has been coming t o t h e i r house p r i v a t e l y and a t t e n t i o n t o her.  paying amorous  She has had e p i s o d e s o f d e p r e s s i o n f o r some t i m e .  she has c l u n g v e r y c l o s e l y to her home and f a m i l y .  Apparently  She and her husband have  n o t gone out t o any e x t e n t , and she found t h i s male f r i e n d ' s a t t e n t i o n s an l e t f o r her i n t e r e s t . She  There were no  sexual r e l a t i o n s h i p s i n t h i s  out-  relationship.  has f e l t v e r y g u i l t y o v e r d e c e i v i n g her husband and i s e v i d e n t l y depressed  a t t h i s t i m e , l a c k i n g e x p r e s s i o n , l a c k i n g a n i m a t i o n , b e i n g n o t a b l y underweight a t about 80 pounds, but r e a s o n a b l y w e l l groomed. She g i v e s a h i s t o r y of e n t e r i n g an orphanage when she was y e a r s of age t h e r e was  about  two  and l e a v i n g the orphanage a t age 12 t o s t a y i n a f a m i l y where  a l o t o f s i b l i n g r i v a l r y w i t h the n a t u r a l c h i l d .  t o a s i s t e r who  a p p a r e n t l y became s c h i z o p h r e n i c about the age  o f t u b e r c u l o s i s i n a mental h o s p i t a l at age 2 3 . for this g i r l .  She was  very close  of 14 and d i e d  She e x p r e s s e s v e r y c l o s e r e g a r d  She m a r r i e d i n ( I r e l a n d ) and came t o Canada i n 1 9 — .  She  has  I t was s t a t e d e a r l i e r t h a t each person r e f e r r e d t o the M e n t a l H e a l t h C e n t r e , A d u l t C l i n i c , was a s s e s s e d by a p s y c h i a t r i s t and a r e l a t i v e was seen by a s o c i a l worker. T h i s assessment note by the p s y c h i a t r i s t i s a r e p o r t o f h i s i n v e s t i g a t i o n and i s i n c l u d e d here f o r i l l u s t r a t i v e purposes as s i m i l a r r e p o r t s were used t o compile the case a n a l y s e s f o r t h i s t h e s i s . The s o c i a l worker's r e p o r t (Appendix "B") i s i n c l u d e d f o r the same r e a s o n . 2 -This i s shown i n such - symptoms as i n a b i l i t y t o e a t , weight l o s s , mood change and d e p r e s s i o n .  - 91 frequently had nervous symptoms of her heart beating fast and feeling giddiness and nausea, of being lonesome.  Her husband i s six years her senior and  the boyfriend who attended her was nine years her senior. fer father-daughter relationships with men.  She appears to pre-  She openly acknowledges f l i r t i n g  with them and finding i t flattering to have them respond, but she does not seek sexual relations.  She reports the cause of the breakup of the family to have  been incestuous relations between her father and an older sister. She reports her husband to have had a serious breakdown and to suffer from nightmares when he walked in his sleep. g i r l s , aged 4 and 2.  They have two children,  There appears to have been more l i b i d i n a l  the boyfriend than there has been i n the husband.  investment i n  He i s sheltering and protec-  ting towards her, more of a father than a boyfriend.  She feels that he under-  mines her self confidence by criticizing her ability with the children and i f they are sick, he insists that she worry about them; otherwise, he i s i l l - a t ease. This appears to be a depressive reaction in a hysterical, f r i g i d woman with a deprived background.  Because of her inclination to manipulate  relationships with men, i t i s proposed that she enter Day Hospital with a view to intensive therapy, somnolent insulin and personal relationship with a female therapist.  Miss  (social worker) has been asked to interview her i n this  regard'. Husband i s to be seen in social assessment as well.  Psychic energy related to sexual drives  - 92 APPENDIX "B" SOCIAL WORK ASSESSMENT - CASE A (husband of the Patient was Seen by a Male Social Worker)  Source of Information The spouse of the prospective patient was seen on January 9» the day he accompanied his wife for her assessment interview.  19—»  Mr. A. i s a  department manager of a large chain store i n the city.  Onset and History of Illness Within and Extending From the Family Mr. and Mrs. A. are (Irish), having been in Canada five years. have been married ten years, have two children, aged 4§- and 2 years.  They  Mr. A.  points out that during the f i r s t five years of their marriage, they were childless, despite their desire to have a family.  He states unawareness of any  reasons which may have made i t possible for his wife to have a child shortly after coming to Canada. Mr. A. is 37 years old, his wife is 31•  Mr. A. i s  eager to declare that he sees himself responsible, in part, for his wife's present condition.  He thinks that his wife's illness, mainly that of depres-  sion, was triggered by an affair she had with his best friend. He adds that although their relationship had apparently ended some time prior to his wife's becoming concerned, she was not able to l e t the matter rest because of a planned v i s i t for Christmas by the man and his wife.  Apparently Mrs. A. finally  broke down prior to the proposed v i s i t and told her husband a l l . friend over, and they discussed the matter.  He called his  The friend stated that he had a l -  ready told his wife about i t long ago and that, as far as he was concerned, the matter was finished. Finished or not, Mr. A. feels that his wife is s t i l l upset by i t a l l , especially from feelings of guilt.  He states that at the time  - 93 -  of her confession, she wanted him to beat her up and to punish her in some way.  He states he could not do this, as he could see no point to i t . Mr. A. describes his wife as a woman with an impoverished upbringing,  having spent her l i f e in an orphanage.  This might have something to do with  the apparent overprotectiveness which she indicates towards their two children. Mr. A. points out that the situation was improved in this regard, but that i t had been bad for some time in that his wife could not, or would not leave the child to be cared for by someone else, i n order that she and her husband could go out.  Even though Mr. A. states that the present affair has caused the wife  to be the way she presently i s , he went on to talk about her as always being a nervous and depressed individual.  He states his wife has had increasing fear  about being i n crowds and going anywhere by bus.  In fact, I gather that she i s  able to spend most of her time at home through her various fears.  I t i s at  this point that Mr. A. talks about his own responsibility i n not taking more initiative so that i t would be possible for his wife and himself to get out and enjoy more social contacts. I gather that the situation at present i s that the A.'s spend most a l l of their time at home, rarely getting out anywhere. Another fear Mr. A. attributes to his wife i s one of dread to be associated with anything "mental". Apparently she showed some reticence at even coming into the building when she saw the notice outside.  Tentative Social Work Assessment Mr. A. presents many doubts about whether or not he is "doing the right thing" for his wife during her illness.  He states that he has recognized  his need to get "counsel" on how best to manage the situation.  He makes i t  - 94 -  quite plain that he i s a person with feelings and that his wife's recent affair has not been the easiest thing for him to take.  He adds that he has  an ulcer that he must care for. I found him to be a rather passive man, who was not too prone to look closely into the reasons for certain happenings i n the marital relationship. When he does look, he tends to look for reasons which are quite acceptable to him.  I notice that whenever I try to take him  from a predetermined pattern, that he was unable to get too involved i n any meaningful explanations.  As mentioned above, he is quick to state that per-  haps he has not been devoting as much of the kind of attention to his wife as she requires.  I f e l t that, i n this way, he was able i n part to explain away  or soften the blow of his wife's interest i n his "best friend". I f Mrs. A. i s extended treatment by this Centre, I would think that Mr. A. might profit from some involvement in a group of spouses.  - 95 APPENDIX "C" BIBLIOGRAPHY  A. General  Eisenstein, Victor ¥., Neurotic Interaction in Marriage. Basic Books Inc., New York, 1956. Hollis, Florence, Women in Marital Conflict. Family Service Association of America, New York, Second Edition, 1957• Stewart, Charles William, The Minister as Marriage Qpunselor. Abingdon Press, New York, 1961.  B. Specific  Bernard, Jessie, Social Problems at Mid-Century. Dryden Press, 1957. Boehm, Werner W., Social Casework Method in Social Work Education. (Vol. X, Social Work Curriculum Study), Council of Social Work Education, New York, 1959. Hinsie, L land E., and Campbell, R. J., Psychiatric Dictionary. Third Edition, Oxford Press, i960. e  Artjcjes Brangwin, L. C., "Marriage Counseling - the Viewpoint of the Caseworker," Social Casework. Vol. XXXVI, No. 4, April, 1955. E l l i s , Albert, "A C r i t i c a l Evaluation of Marriage Counseling," Journal of Marriage and Family Living. February, 1956. Geist, J., and Gerber, N. M., "Joint Interviewing: A Treatment Technique with Marital Partners," Social Casework. Vol. XL, No. 2, February, i960. McCann, Charles W., "Role Theory and Professional Responsibility", Social Worker. Vol. XXIX, No. 3. June, 1961.  -  9 6  -  Maas, Henry S., "Social Casework", Concepts and Methods of Social Work, ed. "Walter A. Friedlander, Prentice-Hall, Second Edition, 1959. Meyer, C. H., "The Quest for a Broader Base for Family Diagnosis", Social Casework. Vol. XL, No. 7. July, 1959. Olds, Victoria, "Role Theory and Casework, A Review of the Literature", Social Casework. Vol. XLIII, No. 1, January, 1962. Perlman, Helen, "Intake and Some Role Considerations", Social Casework. Vol. XLI, No. 4, April, I960. Regensburg, Jeanette, "The Curriculum Study: Implications for the Practice of Social Casework", Social Casework. Vol. XLI, No. 1, January, i960. Spiegel, P., "The Resolution of Role Conflict Within the Family", A Modem Introduction to the Family, ed. N. W. Bell and E. F. Vogel, Free Press,  I960.  Stone, A., and Levine, L., "The Dynamics of the Marital Relationship", Readings in Abnormal Psychology, ed. L. D. Crow and A. Crow, L i t t l e f i e l d , Adams and Co., 1958.  Theses Hawley, Constance M., Role. Stress and Social Work Practice. Master of Social Work Thesis, University of British Columbia, I 9 6 I . Morton, Betty Marie, The Psvchodvnamics and Treatment of the Male Partner i n Marital Conflict Cases. Master of Social Work Thesis, University of British Columbia, 1957.  

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