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Nicki* was a 35-year-old surgical resident when she and her husband began having serious problems in their marriage and started couples counseling with Richard Archambault, a family therapist in Providence, Rhode Island. The couple was in therapy for two and a half years—initially going two to three times a month and eventually tapering down to one monthly session. Here, Nicki and Dr. Archambault discuss why she and her husband entered therapy and how it transformed their marriage.

Nicki: We started therapy at the end of my first year of residency. We had been together for seven years and married for one. There was a lot of pressure in our lives with my training and my husband having a new job, and we were beginning to have trouble communicating. Then my husband started showing signs of depression—concentration and memory issues, and a lack of motivation. At that point, we realized there were deeper issues in the relationship that we weren't addressing. My husband felt that he was "second" to my work. And he was concerned that my focus on advancing my career meant I wouldn't ever have time for children. He also felt that his own career goals were not a priority.

Dr. Archambault: Most couples know what their issues are. They know what's going on, but they just can't talk about it, or it's too sensitive or maybe too explosive. When they bring it into therapy, it becomes more manageable, safer. Often the causes of stress are not big, overwhelming concerns but rather relatively small, everyday things that seem hard to change. My job is identifying those issues, getting the couple to articulate them, and finding ways for the couple to work on them.

Nicki: I had no control over my schedule, and there was a lot of anxiety in the relationship because of that. Surgical residents can work more than 100 hours a week, leaving very little time for anything other than eating and sleeping. I had no time even to care for myself, and my husband had become very frustrated about how I wasn't contributing to the home and how he was bearing the brunt of the responsibilities. That was a major sore point. And even when I was home, I was a shell of a person. I felt a lot of guilt and blame for not being able to devote everything to the relationship.

My husband resented that I had no time. But I suppose even if we had time, we wouldn't have utilized it to sit down and really talk, because we'd started to grow apart.

Dr. Archambault: In any kind of couples therapy, you have an "I" and you have a "we." It's okay to be an "I," an individual, but you also have to be a "we." I try to get the couple to step back from their individual perspectives and look at a problem from the perspective of the relationship. This helps them understand that while they may not have control over work or stress or children or many other things, they do have control over their relationship.

As a therapist, I first observe the strengths and problems in the way the couple interacts, and then help them recognize and identify ways they can improve their relationship. To do this, I point out perspectives and behaviors I think are working and not working. Then I try to help the couple reshape those things in order to make their relationship more effective.

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