8. Questions of Appraisal, Referral, and Extended Counseling

I.  APPRAISAL

This is a better word than "diagnosis," because it suggests the consideration of the many and varied complex factors in the disorder, and also the assets and liabilities of the partners regarding possible solutions of the conflicts.

As the interviews with each partner and any joint interviews proceed the counselor will be almost automatically arranging the facts and feelings presented to him in some kind of evolving pattern. He will also be assessing the various elements of the trouble, and the capacities of the two partners to deal with the situation and to make use of the counseling. It is vital that he make no attempt to disclose his assessments to the partners, because they are necessarily tentative in any case and open to continuing modification, and also because the partners would generally not be at all receptive of such disclosures. If he is pushed for some assessment it is generally possible to turn the question back by asking how the partner or partners feel about it.

As Dr. Paul Tournier has wisely pointed out in his book "A Doctor's Casebook in the Light of the Bible" (S.C.M. Press, Ltd., London, 1954), there are two diagnoses in any illness.

The first is objective, made by the doctor from the data given to him, and ascertained by his examination and from special investigations. The second is subjective, made only by the patient, with help if need be through the quality of the doctor-patient relationship. Such inner feelings as resentment, guilt, anxiety, pain, love and hostility can be suspected but never adequately assessed by anyone but the person in whom they operate, and this subjective diagnosis or "insight" cannot be imposed or even conveyed to people in emotional disorder from outside.

Apart from this "automatic" arranging of the partners' ex­periences and feelings about them and about each other it is often important for the counselor to pause at times, in and be­tween interviews, to make a more detailed appraisal of the situation so far revealed to him. He can do this more clearly if he has in mind certain particular aspects on which it can be based.

a. The personal qualities and attitudes of each partner. One of the most important matters to consider, particularly when the partners are still living together, is whether either one can stand up to the conflicts for long enough for the counseling to have time to become effective. In many cases a partner will decide this for himself or herself and if it seems unbearable will walk out. But in some cases "walking out" is practically either impossible or appears too drastic to contemplate, and yet one partner may be on the verge of a breakdown in health or emotional balance. In such cases it may be of urgent im­portance for the counselor to refer that partner to a doctor for help, or to take some quite directive measures to avert a possible catastrophe. People under extreme stress often show quite surprising stamina, but there seems no adequate reason why anyone should be exposed to stresses which might prove too great for him to cope with.

Similar considerations might sometimes apply when it ap­pears that any of the children are being exposed to extreme stress or danger. This may be difficult to assess from hearing the partners' stories, and there is always some tendency for children to suffer from the conflict to some considerable extent. Here again when there is any suspicion of over-severe stress medical help should be considered, or in some cases when avail­able the help of a social worker or a minister.

Apart from the risk of possible breakdown the counselor may well try to assess the capacity of each partner for reason­able insight through further counseling, and for avoiding desperate impulsive actions which might ruin the chances of reconciliation. Assessment of such matters will help the coun­selor to decide how much counseling to offer either partner, and whether any immediate referral is advisable. For example a partner who seems to be suffering from paranoid delusions is not likely to have any adequate capacity for insight, nor is any partner who may seem to be suffering from any psycho-neurotic, psychotic or psychopathic personality type. A psy­chiatric referral is generally advisable in such cases, if possible through the partner's own doctor.

Other important matters for personal assessment are con­cerned with attitudes to sex, to personal relationships (pos­sessive, dictatorial, judgmental, over-dependent, aloof, or over-sentimental), to parental attitudes, and to religion. Ques­tions of rigidity or flexibility, and rationality and irrationality may be considered in all these aspects of personal attitude, and the general intelligence and maturity of each will come under some assessment, together with general sensitivity and vulner­ability.

As before it must be emphasized that any such appraisal is entirely tentative, and that it is not disclosed to either partner. It is constantly kept under review and modified with each further revelation in the counseling. In some cases the part­ner's insight may be helped by a question such as, "Does your violent reaction to your wife's remark suggest that you have a vulnerable point there?" and possibly later, "Did you ever have any experience like that as a youngster?"

b. The quality of the relationships between the partners. This may show many emotional elements which are not seen in the attitudes of either partner to people other than the mari­tal partner. Many a person shows the most charming manners and the most thoughtful consideration to everyone else but his marital partner. There are many emotional reactions which seem to be brought about by the very fact that the two people are "tied together" in marriage, a tie which may be resented as an "interference with freedom" even though it was accepted willingly and even with intense desire in the first place.

The relationships, for purposes of assessment, may be thought of as personal, sexual, parental, and sometimes speci­fically religious, for example in a "mixed marriage." Questions of compatibility, cooperation and love can be considered in these fields, together with such matters as role perceptions in marriage, role expectations and consequent role frustrations. Such assessment will give the counselor some valuable data on which to base his continuing management of the counseling or his referral.

c. Environmental factors in the marital disorder. While not generally being the most decisive factors these can be strong contributory factors to marital disorder, and it is im­portant for the counselor to give them full consideration in his appraisal of the total situation. It may be that some atten­tion to housing, suitability of neighborhood, suitability of job, influence of "in-laws," matters of finance and other such environmental factors will help in the reconciliation. Social agencies may be of great help in dealing with some "problem families" in this way.

2.  REFERRAL

The essence of marriage counseling is in team work, not only among marriage counselors themselves, but also between them and suitable members of a comprehensive panel of con­sultants. As already mentioned these consultants are profession­ally trained people of special competence in an appropriate field related to marriage, who are willing to see clients referred to them, generally at their own professional rooms or offices, under a mutually acceptable financial arrangement.

As we have seen they can be divided into two groups, those who are especially competent in the counseling and psycho-therapeutic fields, such as psychiatrists, psychologists, and some pastors and social workers; and those with little or no training or experience in the psychological areas but expert in some limited field such as gynecology, urology, medicine, pediatrics, social casework, law, ethics, religion, vocational guidance or child guidance. Other specialists, in such fields as finance and "home economics" or "domestic science" may have a part in some special cases. As also emphasized these consult­ants should have some continuous contact with the marriage counseling agency with which they work, and some acquaint­ance with the principles and goals of the work.

The main reason for referral is that the apparent difficulty for which counseling is sought has some elements in it which are beyond the scope or the training or experience of the marriage counselor, and are within the special competence of the consultant. In this way the counselor can refer the part­ners to someone known to have the most adequate knowledge and experience for this portion of the situation, and can then use his own experience to help with the marital relationship itself. When there is smooth cooperation between the various members of the "team" the clients will receive the best avail­able total help.

Much referral will naturally be governed by availability of the appropriate consultants, geographically, and from the points of view of finance and time. Marriage counselors are generally aware of the available resources in the community for such consultation, and the conditions on which clients are accepted, and this prevents disappointment and frustration.

The actual process of referral is one which needs careful and tactful handling by the counselor because it may cause some strain to any client who has "summoned up courage" to come originally for the counseling and experienced some rap­port with the counselor. The prospect of going over some of the possibly painful material again, and the suggestion that referral means that the situation may be more serious than anticipated, may produce considerable anxiety and even re­sistance in the client.

It is generally best for the counselor, at some appropriate opportunity in the discussion, to begin with a simple bit of information such as, "This seems to be a little outside my par­ticular field, and I think you could be helped better in this by someone with special knowledge. How would you feel about letting me refer you for some special help in this part of the trouble?" If the client shows any hesitation about accepting the idea, he can be encouraged to verbalize his feelings on the matter, with the full acceptance of them by the counselor. When this is done the client will not be so likely to feel pushed around or rejected by the counselor, and the referral may then proceed more smoothly. It is generally much easier to negotiate a referral for the purpose of obtaining special help in a limited field (such as legal or gynecological) than in the deeper psy­chiatric field.

Any suggestion that either client may need psychiatric help may stir up hostility and defensiveness, especially when the partner has already said the same thing to him previously. It is unfortunate that such an idea of need for psychiatric help is still commonly regarded as a slur on a person's character, and it is generally safer for the non-medical counselor to suggest the need for "medical help" which may be more readily ac­cepted, and the doctor can easily recommend psychiatric help if he thinks fit. In any case it is best to refer anyone needing any kind of medical help in the first place to his own doctor.

What kinds of trouble might be referrable for psychiatric help through the client's own doctor or some physician of his choice? In some cases the need is quite obvious. Completely irrational delusions, depression that shows any possible risk of suicidal tendencies, the over-enthusiasm that goes beyond rea­son and involves the risk of spending far too much or doing without sleep, which is characteristic of mania, the complete inappropriateness of feeling or action of the young schizo­phrenic, and any other kind of mental attitude or social be­havior that may be harmful or obviously irrational. Any sexual problems which do not respond to simple counseling are also best referred in this way.

Some people show quite intense psychic symptoms such as deep moody depression at home, but seem to be able to carry on a responsible job and to get on reasonably well with their associates. In fact they can be natural and gracious with every­one else, but utterly ungracious with their marriage partner. This suggests some deep elements of hatred or jealousy, or morbid guilt, and such conditions may respond very well to more prolonged counseling. But if they do not seem to respond to some extent with the achievement of rapport they may be better referred, especially if the counselor has not had much experience.

Among the less obvious referrals we may think of the less seriously depressed people who may yet be greatly and quickly helped by special psychiatric treatment and are not helped by prolonged discussion, and the obsessed who are also more often harmed than helped by repeated discussion of their feelings and urges. We may also include the various forms and mani­festations of psychopathic personality, already mentioned in the chapter on contributory factors in marital disorder. Peo­ple with extreme and persistent anxiety, indecisiveness, phobias, and over concern with an incessant variety of symptoms may also be referrable when their troubles are getting in the way of marital cooperation, but it is not always necessary that neu­rotic trends should be dealt with unless the sufferer wishes to do something decisive about them. Neurotic elements in hus­band and wife may even balance one another well in marriage, to such an extent that any radical change in one of them may even injure the whole balance and bring unhappiness to both partners.

Finally among the psychiatric referrals we may include any case in which the counselor feels that in spite of the fact that a client's statements are plausible, coherent, and sincere it is difficult to make adequate sense out of them, or possibly to decide whether there may be a delusional element in them. Such people and any which the counselor is unable to "sort out" are best referred. Anyone who develops undue depend­ence on the counselor should also be considered for referral.

There are some important ways in which any referral can be made most effective. It is important in the first place to give all the possibly relevant facts that are known about the client and his situation, but the counselor should be sparing about his opinions. It is also helpful to the consultant when the counselor states what has been so far attempted and with what result, and when he can give any other information about the client's background and relationships.

The counselor should state in referring what is being re­quested from the counselor: appraisal for help in further coun­seling or further referral, or the total care and further treatment of the trouble by the consultant, with or without continuing participation by the counselor. It saves possible disappointment if the counselor does not "build up" the consultant by such remarks as "He will put you right in no time!" A simple state­ment that the consultant is regarded as the most suitable per­son from whom to seek this help is enough.

In many counseling agencies consultants have been of great help in many cases which do not necessarily involve referral of the client in person to them. They can often suggest a helpful line for the counselor to take in a discussion of the case on the telephone, which is often effective and less time consuming for the consultant. Discussions of this kind also help the con­sultants and counselors to come to know each other better and achieve better team work. They also provide a valuable alter­native resource in cases in which the desired referral is either impracticable because of distance time or finance, or because of the unwillingness of the client to visit the consultant.

In the larger counseling agencies in some countries it has been found helpful and practical to have psychiatrists regularly visiting the counseling center for consulting purposes, and also for general supervision of the counseling work, including case conferences with the counselors and any trainees who may be invited. This again adds greatly to the total efficiency of the work and to the quality of the team work, and it will certainly become more and more the normal practice. Other types of consultant will also be brought into the visiting staff as occa­sion demands. This naturally makes for much smoother and more effective consultations, but it would only be practicable in counseling agencies of a reasonable size.

3.   EXTENDED COUNSELING

After several interviews with one or both partners indi­vidually, some joint interviews, and possibly some referral to one or more consultants, the time may be ripe for a careful re­view of the situation with a view to deciding about the feasi­bility and value of further counseling. Some counselors make it clear in their defining of the aims and methods of counseling in the early stages that they will give up to a certain number of interviews, and then will review the whole situation with the clients in this way. This has some value, firstly in making sure that the clients realize that their trouble may need more than one or two interviews, and secondly in making them aware that they cannot leave everything to the counselor and take little active part themselves.

In discussing the conditions which affect the decision for extended counseling and the possible ways and methods of con­ducting it we face a practical difficulty. Every case is essen­tially unique, and it is quite impossible to chart out the whole process of counseling. Even if a complete verbatim case record were taken from tape recordings it would not necessarily be of sufficient help in other cases, and it would take up much more space than would be justifiable in this book even if the author had access to any such tape recordings. An attempt has been made so far to provide a reasonable account of the actual work of marriage counseling and to give summaries of portions of the discussion of some common problems, and we are now to con­sider some of the criteria and methods of extended counseling, to be decided at the time of reviewing the individual case after a reasonable amount of counseling. This can be attempted by considering some alternative situations.

In the first place, if the counseling seems still to be proceed­ing satisfactorily and some progress is being made, it would generally seem right to go on and to give the situation more time to work out. Any ideas about how much time might be required are necessarily arbitrary, and as long as the clients feel that they are being helped enough to warrant continuation there would seem to be no reason for stopping. It often takes considerable time and patience for deep wounds to heal, and for some of the more "difficult" realities of the situation to penetrate sufficiently into the obstinate minds of many people to enable them to face the difficulties honestly and work through them into a new and more realistic chapter of their marital enterprise.

A second kind of situation is that in which the clients, or at least one of them, are willing to go on, but the counselor has some doubts of the efficacy of further counseling. It may be that one or both are repeating the same old complaints or making the same unreal demands, and apparently just using the counseling as an opportunity for unproductive self assertion. The counselor will of course "reflect" this back by asking appropriate questions, such as, "You're still insisting that your wife must do what you want in this in spite of all your ac­ceptance of her need to live according to her own conscience, and we have been into some of your background reasons for your attitude. How would you think I can help you further in this?" Or in the case of an incurably suspicious wife, "You still can't accept his repeated assurances that he's "playing the game" with you. How can I help you in further counseling?"

The counselor is not necessarily put off by such apparent "stalemate" situations, even when his efforts to find out why the client persists in such attitudes appear fruitless. He may be able to help the other partner to better ability to accept the unreal demands, complaints and suspicions without neces­sarily acceding to them, so that the partners may come better to "agree to differ" without the necessity of continued destructive and mutually distressing conflict. Time heals many things if given enough chance, and we may remind ourselves that many partners have a greater "vested interest" in staying to­gether, even with constant quarreling, than they are ready to admit to the counselor or to each other.

A third kind of situation is that in which one partner seems to be suffering from a condition for which no treatment is likely to give any great relief. It may be that the counselor has a psychiatric report to the effect that the best that can be done is to keep the person under reasonable observation, with hospital or institutional care available if there is any "relapse" or other difficulty. People who are haunted by fixed delusions come into this category, and so do some of the psychopathic personalities. They may provide a difficult problem for the counselor, but he is often in a different situation from that of the professional psychotherapist. In dealing with the relation­ship rather than the intra-personal dynamics of the partners he may still be able to help some apparently "hopeless" cases to make a better job of ordinary living than he realizes, as long as either partner will cooperate with his efforts.

If the counselor allows himself to feel defeated in the face of apparently incurable psychic illness which is yet mild enough for a person to be able to live outside institutions he may deprive the sufferer of some valuable support which could make him easier to live with. He might also deprive the partner of the sick person of some greatly needed support and help in the difficult and distressing task of living with such a mentally ill person.

A counselor's pessimism and defeatism will certainly be felt by the clients, who are then denied the uplift of spirit which would often make the difference between the success and fail­ure of their courage and endurance. This may well be the last real opportunity such clients may have of receiving such a "spirit transfusion," and it is one of the great strengths of good counseling that it often inspires one or both partners to face a grim and unpleasant reality after exploring all possible alter­natives, and to achieve a courageous acceptance of an "incur­able" partner as he is.

It is an interesting and gratifying fact of life that in some cases, when such an "impossible" partner comes to feel ac­cepted as he is, without any more pressure on him to change, he may, by some strange perversity, begin to grow and to change. The greater their experience the more cautious mar­riage counselors will be in giving up hope for any marriage, and this optimistic attitude of mind will add much to their influence on their clients.

This may happen particularly in some less obviously "incur­able" cases such as alcoholics, who provide their partners with many extra burdens. In most countries the most helpful organ­ization known as "Alcoholics Anonymous" is available to help alcoholics of either sex to "stay sober," and there are increasing clinical psychiatric facilities being developed to help them to discover and to deal with the underlying personality disorder. In most countries there is also an organization associated with "A.A." in which the wives of alcoholics can receive much support and help in handling their difficult situations, and these bodies put out simple literature with suggestions from their experience. The partners of mentally ill people also need help of this kind, and it may be a valuable part of marriage counsel­ing services to give such support and practical help to the partner in handling the problem so as to promote the most comfortable conditions for everyone including the children.

The decision of the counselor about extended counseling may often be helped by discussion of the whole case at a case conference of counselors and possibly consultants as well. His own resume of the case will clarify it in his own mind and the comments of his colleagues and some of their questions will often open up a previously overlooked aspect of the case. But ultimately the decision must be made by the counselor himself, and if he does not feel disposed to go on, it must be conveyed to the clients in terms and attitudes which will not appear "rejecting." Fortunately this does not very often arise. Many of such clients will realize the situation and terminate the coun­seling on their own initiative.

If the counselor allows himself to be committed to extended counseling, there are various ways in which it can be carried out. As we have seen the counselor may often help greatly in a supportive and educative role once the main emotional com­ponents of the disorder have been sufficiently ventilated. The supportive role may be necessary for a time simply because the client may have nobody else to turn to. It may be an essen­tial part of this extended counseling to encourage such clients to look for other resources in the community for support, such as a church, or a social or cultural or "handcraft" group, or even a part time or full time job where practicable. It is the essence of counseling to help people to help themselves and to overcome any dependency which may be unavoidable for a time.

The educative role of the counselor may also be productive for the clients in extended counseling. Education and healing cannot be separated, and even in the healing of physical ill­nesses the patient often needs to be educated regarding the main principles of healthy living, diet, rest and exercise, and general hygiene. Many disturbed marital partners can be helped by some good education in the principles of personal relation­ships, in matters concerning sexual attitudes and in problems of parenthood.

One aspect of the educational part of counseling which applies at this point more appropriately than in the earlier stages is the use of suitable literature, typewritten material, pamphlets, booklets, magazines, and books. In such cases it is often helpful to offer the opportunity of discussing anything in the literature supplied with the counselor, as referred to in a previous chapter. Lectures may also have a place in some cases, especially when they are accompanied by group discussion.

In some stubborn cases there may be an important part for some kind of group counseling, an activity which is beginning to develop more in recent years. It may include "unstructured" group discussion, "role-playing" in conflicts felt by any mem­bers of the group, including the reversal of the conflicting roles, and also "psychodrama" in which specific questions and problems as well as those experienced by members may be acted out under the supervision of the counselor or a trained therapist. It is probable that there will be a steady expansion of such methods of counseling and psychotherapy in the future.

With extended individual counseling the two most common questions for the counselor to decide concern the dependency of the client and the possibility of the counseling extending more deeply into psychotherapy. He can guard against undue dependency by continually throwing the initiative and respon­sibility back on the client, suggesting some specific "home work" between sessions, either thinking out some particular aspect of his problem or carrying out some project designed to improve the home conditions, or whatever seems appropriate for his further development. He can also increase the time be­tween counseling sessions, so that more responsibility lies on the partners to work things out, even at the risk of more wounds. By accepting the client's feelings of cynicism and encouraging the client to work through them he is also guard­ing against undue dependency.

In extended counseling if the counselor goes beyond sup­portive and educational counseling to persist with attempts to elicit the deeper underlying factors in the partners' attitudes he will probably find himself drawn into deeper individual psychotherapy than he may have allowed for. His handling of this will depend partly on his own training and experience in the conduct of deeper counseling, and partly on the availabil­ity of resources for individual psychotherapy.

He can decide his course of action better if he can honestly assess his own limitations, how "comfortable" he feels in the counseling and above all in the handling of transference and any of the other mental processes described in an earlier part of this book. If possible it may be well to consider further referral, or at least discussion in a case conference, but if he is committed to carrying on and can handle any transference or dependency without becoming involved he will generally do no harm and might do a great deal of good. His prolonged counseling may provide the necessary time and the right atmos­phere for the client to grow steadily in maturity and to achieve gradually improving insight into the deeper elements of the trouble and into the realities of his situation.

If he can keep constantly in the foreground the constantly understood, but not always verbally expressed question to each partner, "What can you offer toward a better partnership, ir­respective of your partner?" it will tend to keep a practical and constructive orientation to the discussions.

In some cases extended counseling may be conducted with one or both partners right through the experience of separation or even divorce. This is an experience in which either partner and probably the children, will need some help, and this aspect of counseling will almost certainly develop greatly in the future. It needs to be realized by the clients from the begin­ning and by the public always that no reputable marriage counselor would have any "vested interest" in trying to induce two unwilling partners to stay together, however foolish he may think they would be to give up the attempt to work things out. He may look with each of them at the reasons for their decision and at the possible consequences to themselves and the children, but the ultimate decision is in their hands and the counselor respects their freedom to make it completely, and goes on accepting each of them whatever they may decide. In some cases the counselor will have the opportunity of interviewing the "co-respondent" or the third element in a triangular situation, and the same acceptance holds there too, with a full encouragement for ventilation of all feelings in the matter. In many cases this accepting relationship is felt deeply, in contrast to the condemnatory attitudes of all kinds of other people, even though it is realized that acceptance does not mean that the counselor condones the action in any way. In such an atmosphere the defenses may go down and the "third party" may be able to look better at the long term implications of what is being contemplated, and then to set out to encourage the re-establishment of the partnership. This has happened in a number of cases.

In all counseling the situation ultimately has to be faced that marriage must always involve some sacrifice of individual­ism, some genuine readiness to give as well as to take, to look beyond one's own concerns and to consider and care enough for those of one's partner to be willing to make reasonable ad­justment to them, whether the partner seems to be considerate or not.

Until the two partners can learn to think in terms of "we" rather than of "I," until their marriage itself comes to receive some reasonable priority in the scale of values of each partner as a creative joint project worthy of the best that each of them can offer to it, they will fail to derive the satisfaction and growth of personality that marriage, more perhaps than any other relationship, can give them. It is such a conviction as this which animates and sustains all efforts of marriage coun­selors to hold fast to their work even through times of great difficulty and doubt. But the results are constantly confirming their inner convictions and strengthening their staying power.

In conclusion it may be stated that with all its trials and difficulties marriage counseling is the most rewarding work, constantly strengthened by the awareness of its creative results. The regular renewal and re-creation of threatened, disturbed, and even broken marital partnerships, and the realization that the benefits which come from this healing work go on through the children into the next and future generations, produce in marriage counselors a steadily deepening devotion to their high calling, which is further inspired by the com­radeship and team work between them.

There can be few healing works which can promise such consistent and far reaching benefits to people and to the whole community, and we shall probably come to realize that in the underpinning and healing of home and family life, the greatest of all possible contributions is being made to the prevention of mental, social and even much physical illness, and still better to the promotion of total health, in the best sense of that term, in the communities of the world. It is hoped that this book may in some small way add its contribution to the personal and community welfare in this important and growing field of creative service.