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A component analysis of behavioral marital therapy: 1-year follow-up
Behor. Res Ther Vol 23. No. 5, pp. 549-555. Prmted m Great Bntain. All rights reserved
A COMPONENT
1985
OOOS-7967/85 $3.00 + 0.00
Copyright
ANALYSIS
THERAPY:
OF BEHAVIORAL
l-YEAR
NEIL S. JACOBSON, VICTORIA M. AMY
HOLTZWORTH-MUNROE,
Department of Psychology.
(Receioed
1985 Pergamon PressLtd
MARITAL
FOLLOW-UP*
FOLLETTE, WILLIAM C. FOLLETTE,
JANICE L. KATT
University
c
and KAREN B. SCHMALING
of Washington,
10 Junuar~
Seattle.
WA 98195,
U.S.A.
1985)
Summary-The present study provides I-yr follow-up data for a comparison between a complete behavioral marital therapy package (CO) and two of its major components, behavior exchange (BE) and communication:problem-solving training (CPT). each presented in isolation. Data are reported for 60 married couples who were randomly assigned to one of these three treatments or to a waiting-list control (WLC) group. Four doctoral candidates and one masters-level counselor served as therapists. All treatments involved 12-16 therapy sessions. The long-term effects of therapy were evaluated with measures of global marital satisfaction and presenting problem checklists. While BE couples tended to reverse their protress relative to those in the CO condition during the first 6 months following termination, statistically sigmficant differences between groups were no longer in evidence by the I-yr follow-up. However, couples treated with CO were most likely to be happily married and least likely to be separated or divorced.
INTRODUCTION
Over the past five years. we have been involved in a study which compared our version of behavioral marital therapy (BMT; Jacobson and Margolin,’ 1979) with two of its major components. One component. behavior exchange (BE), instigates increases in positive marital exchanges at home. BE focuses heavily on behavior change directives delivered by the therapist to be implemented as homework assignments between sessions: process issues between spouses during the therapy session are deemphasized. BE interventions include pinpointing rewarding and punishing relationship events, directing spouses toward targeted increases in positive behavior and trouble-shooting as well as debriefing the success or failure of these homework assignments. A second component is called Communicationlproblem-solving training (CPT). CPT is in many ways the opposite of BE. It emphasizes teaching process-interaction skills during the therapy sessions. especially those involved in conflict resolution. There is a deemphasis on instigative interventions designed to promote an increased frequency of positive exchanges at home. CPT is conceptualized as a preventive approach: successful acquisition of these conflict-resolution skills is supposed to arm couples with the tools they need to become their own therapists, so that the skills can be utilized after therapy is over and thereby prevent the return of significant marital distress. Jacobson (1984b) reported results for the first 36 couples treated in this study. Both the component treatments and the complete (CO) treatment led to significant improvement relative to untreated couples. but at posttest the three active treatments appeared equally effective. However, at a 6-month follow-up. BE couples showed signs of relapse, whereas both CPT and CO couples seemed to maintain their treatment gains. This component analysis is important for a number of reasons. First, given the multifaceted nature of BMT. clinicians need to know which ingredients are accounting for its effects. Second, the analysis allows us to begin identifying the change mechanisms in BMT. Each procedure is expected to produce particular types of changes at particular rates. By comparing these components with one another and with the total treatment package, one can evaluate the extent to which BMT *PortIons of this manuscript were presented Philadelphia. Penn.. November 1984.
at the Meet.
of the Association
549
for
the Advancement
of Behavior
Therapy,
550
NEIL
S.
JACOBKIN CI ui.
works for the reasons hypothesized by its leading theorists. In particular. it was predicted that BE would produce relatively strong immediate effects, with its emphasis on immediate behavior change, but not much was expected in the way of continued improvement subsequent to termination. Moreover. relapse rates were expected to be higher in this condition than in the other two, since BE deemphasized prevention. In contrast. CPT couples were expected to show relatively weak immediate effects, but whatever effects were obtained were expected to be maintained. Moreover, since much of CPT is devoted to encouraging the application of conflict-resolution skills subsequent to therapy, there was some expectation that CPT couples would continue to change for the better after posttest. Finally, CO couples were expected to receive the best of both worlds. The BE component should produce strong immediate effects, while the CPT component was expected to lead to the maintenance of these changes. The purpose of the present study was to evaluate the long-term effects of these three treatments, by collecting data from couples 1 yr after treatment te~ination. Data are reported on 43 couples who had been randomly assigned to and completed one of the three treatments. METHOD
Subjects There were 60 couples who completed BMT in this study: 43 who were treated and 17 assigned to a waiting-list control (WLC) group. Fifty-seven of the 60 couples were married, and all were living together throughout their participation in the project. Couples were offered treatment unless they met one or more of the following exclusionary criteria: a primary complaint of sexual dysfunction or disorder (not including disorders of sexual desire; n = 7): current severe alcohol abuse (n = 1); an acute psychotic episode (n = 2); incapacitating current physical problems which precluded active participation in marital therapy (n = 3); or a current episode of spouse abuse (n = 2). In addition, two couples were refused treatment because they were not distressed, based on our assessment criteria. Out of 67 couples assigned to a treatment condition, 77 dropped out prior to completing the treatment program: 2 couples in each of the three treatment conditions; and 1 WLC couple. Therapists The therapists were four psychology graduate students in training and one masters-level counselor. All treated at least 1 couple in each condition. Excluding the 17 WLC couples, the number of couples treated by each therapist varied from 3 to 16, with a mean of 8.6. Follow -up measures Dyadie A~usiment Scale (DAS; Spender, 1976). The DAS is a widely used self-report questionnaire serving as an index of global marital adjustment. It is commonly used in marital therapy outcome studies and has good psychometric properties (cf. Jacobson. Elwood and Dallas, 1981). Areas of Change questionnaire (AC; Weiss and Perry, 1979). The AC was used to assess the effects of treatment on couples presenting complaints. Part A consists of 34 common marital behaviors and requires that each spouse rate, on a 7-point Likert scale, how much behavior change is desired for each behavior. For example, one item on the AC is “I want my partner to pay attention to me”. Possible endorsement can vary from - 3 (much less often) to + 3 (much more often). When no change is desired the item is rated ‘0’. The AC has been shown to disc~minate between distressed and nondistressed couples (Margolin, Talovic and Weinstein, 1983) and to discriminate between couples responsive and unresponsive to BMT (Baucom, 1982). Part B, which asks both spouses to estimate the amount of behavior change which their partners want from them, was not included in this study. Two measures were derived from the AC. One is simply the total score for part A, which requires adding the absolute Likert values across all items. This is a common scoring procedure (Margolin et al., 1983), and simply reflects the total amount of behavior change desired. The second measure was the percentage of problem reduction (“,/,R). This measure reftected the percentage of presenting complaints where less change was desired at posttest (or at follow-up) than at pretest. For example, if a spouse desired ‘much more’ attention at pretest but only ‘somewhat more’ at posttest, this problem was rated as reduced at posttest.
A component analysis of behavioral marital therapy
551
Procedure Assignment to treatment condition was random. Each couple was seen for 12 treatment sessions, with the option of extending to 16 if the therapist felt that such an extension was clinically indicated. Prior to this treatment regimen, all couples received two assessment interviews in which pretest measures were administered, and a roundtable discussion where they were informed of the treatment condition to which they had been assigned. All posttest procedures were readministered by a research assistant 2 weeks following the final therapy session. Six months and 1 yr following the posttest, separate packets were mailed to each spouse. Included in each packet was a request for a completion of follow-up questionnaire, the questionnaires themselves and a stamped return envelope. The content of each treatment condition is described in the initial report (Jacobson, 1984b). The treatment manual for the project was the Jacobson and Margolin (1979) book, supplemented by more recent clinical innovations (Jacobson, 1984a).
RESULTS Pretreatment characteristics
c2fcouples
Demographic characteristics. Couples in the various treatment conditions were compared on relevant demographic variables, including age (for both spouses), education level (for both spouses), duration of marriage and number of children. The multivariate analysis of variance (MANOVA) failed to indicate statistically significant differences between groups on these demographic measures. Husbands averaged 38.8 yr of age, whereas wives averaged 36.1 yr. Males averaged 15.8 yr of education, and females 15.2 yr. The average marriage duration (or length of time living together in the case of unmarried couples) was 9.7 yr. Couples averaged 1.2 children/family, with one-third of the couples childless. Pretreatment dtflerences on criterion measures. The pretest means for all treatment conditions on each dependent variable are shown in Table 1. To evaluate whether or not the groups were significantly different at pretest, a MANOVA was conducted. It provided no evidence for group differences prior to treatment. Summary
qf immediate treatment eflects
The results for this updated sample of 60 were virtually identical to those originally reported (Jacobson. 1984b). All groups were significantly more effective than no treatment at all, but they were virtually indistinguishable from one another on all criterion measures. The only distinctions to be made between the three active treatments were on measures designed primarily as
Table
I. Pretest.
posttest
and
follow-up
scores on the DAS. condition
DAS Group
AC and
:
AC
“/,Ra
Pre
Post
FUI
FU2
Pre
Post
FUl
FU2
Post
FUI
FU2
90.9 13.6 14
103.5 12.0 14
94.9 12.4 14
93.0 18.4 I4
24.6 1.4 I4
16.9 6.8 14
20.2 7.8 12
20.9 12.3 14
0.49 0.15 I4
0.41 0.1 I 14
0.43 0.21 12
86.9 IO 7 I4
97 5 14.7 I4
97.1 13.0 I4
92.1 14.3 I2
27.5 8.2 I4
14.7 7.3 I4
17.7 8.1 14
21.9 9.1 13
0.54 0.19 14
0.59 0.13 IO
0.53 0.18 7
86.0 13.3
15
99.3 12.4 IS
101.9 13.8 1s
98.4 18.5 13
29.8 10.9 I5
20.3 9.9 I5
21.6 14.2 15
19.0 10.6 I?
0.48 0.14 15
0.56 0.17 13
0.48 0.1 I II
95.9 13 b 17
94.2 15.0 I7
25.1 11.2 lb
22.9 11.6 I6
BE 8
SD h CPT .\’ SD z CO
.i SD .z H.LC .T SD .?!
All scores are for couples (hushand.and for the WLC group “Pretest score omitted because posrtest
wife scores combined). and follow-up
0.37 0.17 I6 Follow-up
scores are adjusted
data were not collected based on pretest
score.
552
NEIL
S. JACOBSON; et al.
manipulation checks. Thus, as described in the earlier paper. BE couples showed greater increases in the frequency of positive behavior exchanged at home than did couples in other conditions. based on the Spouse Observation Checklist (SOC). The SOC is a checklist of pleasing and displeasing behaviors which spouses complete at home. The results were based on 14 days of data collection prior to therapy and 14 immediately following therapy. Groups were also compared immediately after therapy on an observational coding system developed in the laboratory, the Dyadic Interaction Coding System (DICS). The DICS was developed to code the quality of emotional responsiveness and conflict-resolution skills of spouses when engaged in direct interaction with one another. All couples engaged in IO-min problemsolving discussions before and after therapy, based on identified conflict areas in their own relationship. These interactions were videotaped and later coded by a research assistant who was blind to both treatment condition and time of interaction. After observing the entire IO-min interaction, the coder rated each spouse on the following dimensions: affect (AF); attention (AT); acceptance of responsibility (AR); side-tracking (ST); willingness to change (WC): and quality of agreement (QA). Reliability was determined in a number of different ways: percentage agreements between raters ranged from 0.70 to 0.81, with a mean of 75.4%; K-values ranged from 0.56 to 0.79. with a mean of 0.654; correlation coefficients range from 0.57 to 0.93, with an average coefficient of 0.735. Preliminary normative research on the DICS indicates good discriminant validity, with nondistressed couples exhibiting better performance on five of the six codes (all except WC) than their distressed counterparts. The DICS was designed to measure both emotional responsiveness and problem-solving skill using a cost-effective method. It was used to see whether or not couples who received CPT learned the skills that were taught in that condition. Any change on these measures from pre- to posttest in BE couples would be an indirect consequence of an improved relationship, since these couples were not taught problem-solving skills. WLC group couples showed no improvement on any of the measures and actually deteriorated to a significant degree on AF [t(16) = 3.00, P < 0.051 and AR [t(16) = 3.00. P < 0.051. Couples receiving CPT showed significant improvement in AF [t(13) = 3.00, P < 0.051. and QA [t(13) = 3.00, P < 0.051. Interestingly, significant improvement was evident only in the CPT condition. For planned comparisons looking at differences between groups on the DICS. composite scores were used, derived by adding together the scores on all six measures. The basic finding for this composite score was the same as it was for other measures: all groups improved significantly more than the WLC, but the three active treatments were indistinguishable from one another. Summary
of 6-month
follow-up
(FUl)
Some follow-up data were available for all treated couples.* The means and standard deviations on all follow-up measures are presented in Table 1. On all three follow-up measures. BE couples showed deteriorations at FUl. In contrast, as a group both CPT and CO couples tended to maintain or enhance their treatment gains. To directly compare differences between groups at FU 1, planned comparisons of greatest interest were examined: each involved a comparison between CO and one of the two components. For measures of marital satisfaction (DAS) and presenting problems (AC), the comparisons were based on analyses of covariance, with pretest scores used as covariates. For the Oj,R measure, the comparison was based on arcsin transformed proportions
‘For
some analyses (those reported in Tables 2 and 3). couples who chose not to report follow-up data because they were separated at either FIJI or FU2 were counted as ‘unimproved’. Thus, couples were not removed from Tables 2 and 3 when they failed to report data due to separation or divorce. Moreover, in a few cases couples failed to return written questionnaires but were willing to allow administration of the DAS by phone interview. Data obtained by telephone were included in Tables 2 and 3. Finally, instead of excluding separated or divorced couples from between-groups comparisons, these couples were e-/en included in the analyses even when they failed to report data. In instances where data were not reported due to sepamtton or divorce. either the pretest score or posttest score was subsutured for the mrssmg follow-up score. The rule was that whtchever score was lower would be used as the follow-up score in the event that the data were not reported. This seemed to be a conserative practice which could in no way be viewed as self-servtng. Excluding such couples from the analysis would have clearly Inflated the success rate of the treatment in question In an artifcial manner.
A component
Table 2. Treatment
oroeress
Posttest
Groun
N
Enhancemenr
BE CPT CO
14 I4 15
0 21.4(14.3) 33.3 (26.7)
Total
43
1X.6(14.0)
analysis
from oosttest
of behavioral
marital
553
therapy
to FUI. and FUI to FU2. based on the DAS
FUI to FU2
to FUI Deterioration
N
Enhancement
No chance
28.6 64.3 46.7
71.4 (35.7) 14.3 20.0(13.3)
14 I2 I3
21.4(14.3) 0 15.4
50.0 66.1 53.8
46.5
34.9 (20.9)
39
12.8(10.3)
56.4
No channe
Each number reflects the percentage of couples corresponding to the status represented by the particular numbers m parentheses represent the percentage ol couples whose changes were clinically significant, dllked from the overall enhancement or deterioration rate.
Deterioration 28.6 (21.4) 33.3 30.8 30.8 (28.2) column heading. The when that percentage
the percentage of problems identified at pretest that were reduced at the time of FUl. For both measures of marital satisfaction [t(44) = 2.45, P < 0.021 and the percentage of problems reduced [t (36) = 2.13, P < 0.041, CO couples reported significantly more improvement than did BE couples. reflecting
One -J’r folloiz,-up
(FU2)
Changes between FUl and FU2. The process of improvement and deterioration in couples between FUl and FU2 might be best ascertained by examining Table 2. This table shows the relapse rates in each condition during the first and second six-month periods following the end of therapy. as well as the proportions whose relationships were enhanced and maintained during those periods. During the first 6 months following termination, the relapse rates were significantly higher among BE than among CO couples, and a significantly higher proportion of CO couples continued to improve significantly during the course of the 6-month period (Jacobson and Follette, 1985).* In contrast. between FUl and FU2 the groups deteriorate and improve at relatively comparable rates. Almost one-third of the treated sample shows some deterioration during this 6-month period. Relatively few couples improved significantly during the 6-month pericd. However, whereas none of the BE couples improved during the first 6 months following the end of treatment, 1 out of 5 improved between FUl and FU2. In short, while the course of change during the first 6 months was in accord with the predictions, with BE couples at greatest risk for deterioration and CO couples holding their own, this trend did not continue during the second 6 months following the end of therapy. Moreover, substantial proportions of couples in all treatments deteriorated during the second 6-month period. and this deterioration exceeded the rate of improvement during this period. Status qf couples 1 -yr following therapy. Table 3 reports the proportions of couples who are improved. no longer distressed, deteriorated and separated or divorced at posttest, FUl and FU2. At the time of FU 1, the proportions of both improved and ‘no longer distressed’ couples were significantly higher in the CO condition than in the BE condition (Jacobson and Follette, 1985). By the time of FU2. the differences in improvement rates between groups are no longer statistically significant. Slightly more than one-half of the couples across the entire sample remain improved at FU2 compared to pretest. Improvements were clinically significant for slightly more than one-third of the entire sample. It should also be noted that a fifth of the sample was either divorced or had separated at least once by the time of FU2. These separations and/or divorces were confined exclusively to BE and CPT couples.? CO couples were significantly less likely to separate than either BE (z = 1.77, P < 0.05) or CPT (z = 2.49. P < 0.01) couples.
*The rehable change mdex (Jacobson. Follette and Revenstorf, 1984) was used to determine what proporttons of couples in each condition deteriorated or progressed during the follow-up periods. For those couples who had deteriorated, the deterioration was deemed climcally significant if their status at the time of the follow-up placed them closer to the mean of the distressed than the nondistressed population. For those couples who showed statistically significant improvement during the course of the follow-up period. clinically significant improvement was inferred when their follow-up score placed them closer to the mean of the nondistressed than the distressed population. tone CO couple had decided to separate after therapy but remain lovers in a monogamous relationship. This couple was unmarried and had been living in a communal household at the time they entered therapy. Their decision to live apart was not a separation in the sense that the term is usually used; rather, it was an affirmattve decision that their relationship would be better if both had their own residences. Since all other factors indicated clinically significant improvement. thts couple was not considered a casualty.
554
NEIL S. JACOBSON et al.
Table 3. Percentages
of couples
Improved.
no longer
distressed
(ND). determrated
Posttest Gr0Llp
,V
BE CPT co WLC
14 14 15 I7
Total”
43
Follow-up data “Totals exclude bData wadable ‘Data available
ND
Determrated
SD
.V
85 7 71.4 60.0 I7 6
78.6 57.1 40.0 11.8
7.1 0 0 23.5
0 0 0 0
14 I4 15
72. I
58. I
2.3
0
43
Improved
were WLC from from
not collected couples. 13 couples. 40 couples.
and separated
or divorced
Improved
(S DI based on the DAS FL?
FIJI ND
Detervxared
SD
.V
Improved
ND
42.9 64.3 80.0
28.6 57. I 60.0
14.3 0 0
71 28.6 0
I-l I2 I3
42.9 50 0 61.5
28.6 25.0 53 8
Determrated I4 3 0 77
21 -1 38 4’ 0
S D
62.8
48.9
4.7
11.6
39
51 2
35.9
77
20.0
for WLC couples.
of correlated means were used to calculate the Changes within groups over time. t-Tests significance of changes at the group level. The means and standard deviations of these group changes are depicted in Table 1. The Bonferroni procedure was used to correct for the calculation of multiple t-tests. Within group t-tests show significant deterioration among BE couples during the follow-up period on marital satisfaction [t(13) = 2.96, P < 0.011. In contrast, no significant deterioration occurs at the group level for either CPT [t(ll) = 1.26, NS] or CO [t( 12) = 0.40, NS] couples. As a result of deterioration, BE couples are no longer significantly better off than they were when they came into therapy on either the DAS [t( 13) = - 0.58, NS] or the AC [t (13) 1.24. NS]. In contrast, both CPT and CO couples remained improved on both measures relative to their scores at pretest: for CO couples, improvement remained significant on the DAS [t( 12) = - 2.60. P < 0.051 and on the AC [t( 11) = 4.76, P < O.OOl]; similarly, for CPT couples improvement remained significant on both the DAS [t(ll) = -2.08, P < 0.051 as well as the AC [t(12) = 2.27, P < 0.051. Between-groups comparisons. The same planned comparisons used during the FUl were employed at FU2. At this time, none of the group comparisons showed statistically significant differences. In other words, analyses of covariance, based on scores at FU2 with pretest scores used as covariates, failed to uncover differences between the treatments. This failure was repeated with the percentage problem reduction measure. Thus, group comparisons revealed that the significant differences in favor of CO relative to BE that had been found at FUl were no longer evident by the time of FU2. DISCUSSION The updated summary of the immediate treatment effects reported here substantiates the findings in the earlier report (Jacobson, 1984b). BMT, in whatever form, produced significant changes in couples relative to a control group, but immediately after therapy the three versions of BMT were not differentially effective. This updated report also strengthens the 6-month follow-up trends reported in the earlier paper. BE couples showed alarmingly high deterioration rates, while not a single couple in this condition significantly enhanced their marital satisfaction during the first 6 months following treatment termination. In contrast, CPT and CO couples showed relatively low deterioration rates, and almost a third of the couples in these two treatments significantly enhanced their marital satisfaction during the follow-up period. These within-group trends were also reflected in the comparisons between groups and in the proportions of couples who remained improved in each condition at the time of FUl. These differences were in accord with predictions. Thus. at the time of FIJI, it looked as if the skill training emphasis in CPT was paying off. This component appeared to be necessary for the maintenance of treatment gains. However, CPT did not appear to be sufficient in and of itself, given the high separation/divorce rate among CPT couples. The absence of significant differences between groups on most measures at FU2 suggests that the superiority of CO is temporary. There was some evidence of deterioration even in this condition during the second 6 months following therapy. It may be that the combination of BE and CPT provides couples with a temporary boost relative to an exclusive focus on immediate change, but by the time 1 yr has past other factors in the lives of the couple become more salient than the experience in therapy. If this interpretation is correct, one would expect continuing convergence
A component analysis of behavioral marital therapy
555
between the three treatments during the second year following termination. A 2-yr follow-up is currently underway to investigate this possibility. It should be pointed out, however, that even at FU2 there was some evidence for the superiority of the CO treatment. Even after the fairly substantial relapse that occurred between FIJI and FU2, CO couples reported significant improvement on all measures relative to pretest, whereas this was not the case for the BE treatment. CO couples also produced by far the highest percentage of nondistressed couples at the time of FU2. Finally, none of the CO couples had split up as yet, a fairly remarkable statistic. In short, the great majority of CO couples were improved relative to when they entered therapy; a majority of them had improved their relationships fairly dramatically; and none of them had split up. As has already been mentioned, one possibility suggested by these data is that even a skill-o~ented maritai therapy has benefits which are only temporary. Perhaps no matter how initially potent marital therapy is, its influence does not extend beyond an initial period of skill utilization. It is possible that booster sessions would extend the effects of therapy further in time. The idea that a brief time-limited treatment program is a permanent solution to long-standing relationship problems may be naive. The traditional model of discrete intensive treatment periods followed by termination may be insufficient to produce long-term improvements in marital intimacy. Perhaps a more appropriate model to be tested in future research involves the therapist as a consultant (more like a dentist or accoun~nt): once a relationship between the therapist and couple is formed, they come together periodically to work on relationship issues. Above and beyond the issue of maintenance, it is also apparent from the clinical significance data that substantial proportions of couples are not helped at all, even in the CO condition. For these couples, current BMT treatment does not seem applicable. Several lines of research have the potential to look more closely at these apparent limitations of BMT. First, BMT could be evaluated in studies using more experienced therapists, under treatment conditions that are less constrained by typical research considerations. Second, treatment failures could be intensively analyzed (Barlow, Hayes and Nelson, 1984). Third, attempts could be made to integrate BMT with other approaches. Acknowledgemenrs-This research was supported by Grant No. 2 ROl MH 33838-04 from the National Institute of Mental Health. awarded to N. S. Jacobson. Special thanks are due to therapists Kathy Melman, Lisa Wood, Debbie McDonald and Bob Berley; and to research coordinators Carolyn Phelps, Nicole Bussod and Christy Crose. Requests for reprints should be addressed to N. S. Jacobson.
REFERENCES Barlow D.. Hayes S. and Nelson R. (1984)The Scienrisr Practitioner: Research and Accountubility in Clinical und Educarianal Setrings. Pergamon Press. New York. Baucon D. H. (1982) A comparison of behavioral contracting and problem-solving/communications training in behavioral marital therapy. Behav. Ther. 13, 162-174. Jacobson N. (1984a) The modification of cognitive processes in behavioral marital therapy: integration of cognitive and behavioral intervention strategies. In Ma&al Znteracrian: Ana~_vsisand Modification (Edited by Hahlweg K. and Jacobson N.). pp. 285-307. Guilford Press, New York. Jacobson N. (1984b) A component analysis of behavioral marital therapy: the relative effectiveness of behavior exchange and problem solving training. J. consult. cl&. Psvehoi. 52, 295-305. Jacobson N. and Follette W. (1985) Clinical significance of improvement resulting from two behavioral marital therapy components. Be&au. Ther. In press. Jacobson N. and Margolin G. (1979) Mariral Therapy: Strategies Based on Social Learning and Behavior Exchange Principles. Brunner’Mazel. New York. Jacobson N.. Elwood R. and Dallas M. (1981) Assessment of marital dysfunction. In Eehauioral Assessmenr of Adult Duorders (Edited by Barlow D.). Guilford Press. New York. Jacobson N.. Follette W and Revenstorf D. (1984) Psychotherapy outcome research:. methods for reporting variability and evaluating clinical significance. Beirar. T’er. 15, 336-352. Margoiin G.. Taiovoc S. and Weinstein C. (1983) Areas of change questionnaire: a practical approach to marital assessment. J. cotlsuli. rh. Ps,l+chol. 51, 920-93 1. Spanier G. (I 976) Measuring dyadic adjustment: new scales for assessing the quality of marriage and similar dyads. f. Murr. Fon7. 38, 15-28. Weiss R. L. and Perry B. ( 1979) Assessment and Treatmenr of Muriral Dwfuncrion. Oregon Marital Studies Program, Eugene Oreg. (Write to R. L. Weiss. Department of Psychology. University of Oregon, Eugene, OR 97403.)
A COMPONENT
1985
OOOS-7967/85 $3.00 + 0.00
Copyright
ANALYSIS
THERAPY:
OF BEHAVIORAL
l-YEAR
NEIL S. JACOBSON, VICTORIA M. AMY
HOLTZWORTH-MUNROE,
Department of Psychology.
(Receioed
1985 Pergamon PressLtd
MARITAL
FOLLOW-UP*
FOLLETTE, WILLIAM C. FOLLETTE,
JANICE L. KATT
University
c
and KAREN B. SCHMALING
of Washington,
10 Junuar~
Seattle.
WA 98195,
U.S.A.
1985)
Summary-The present study provides I-yr follow-up data for a comparison between a complete behavioral marital therapy package (CO) and two of its major components, behavior exchange (BE) and communication:problem-solving training (CPT). each presented in isolation. Data are reported for 60 married couples who were randomly assigned to one of these three treatments or to a waiting-list control (WLC) group. Four doctoral candidates and one masters-level counselor served as therapists. All treatments involved 12-16 therapy sessions. The long-term effects of therapy were evaluated with measures of global marital satisfaction and presenting problem checklists. While BE couples tended to reverse their protress relative to those in the CO condition during the first 6 months following termination, statistically sigmficant differences between groups were no longer in evidence by the I-yr follow-up. However, couples treated with CO were most likely to be happily married and least likely to be separated or divorced.
INTRODUCTION
Over the past five years. we have been involved in a study which compared our version of behavioral marital therapy (BMT; Jacobson and Margolin,’ 1979) with two of its major components. One component. behavior exchange (BE), instigates increases in positive marital exchanges at home. BE focuses heavily on behavior change directives delivered by the therapist to be implemented as homework assignments between sessions: process issues between spouses during the therapy session are deemphasized. BE interventions include pinpointing rewarding and punishing relationship events, directing spouses toward targeted increases in positive behavior and trouble-shooting as well as debriefing the success or failure of these homework assignments. A second component is called Communicationlproblem-solving training (CPT). CPT is in many ways the opposite of BE. It emphasizes teaching process-interaction skills during the therapy sessions. especially those involved in conflict resolution. There is a deemphasis on instigative interventions designed to promote an increased frequency of positive exchanges at home. CPT is conceptualized as a preventive approach: successful acquisition of these conflict-resolution skills is supposed to arm couples with the tools they need to become their own therapists, so that the skills can be utilized after therapy is over and thereby prevent the return of significant marital distress. Jacobson (1984b) reported results for the first 36 couples treated in this study. Both the component treatments and the complete (CO) treatment led to significant improvement relative to untreated couples. but at posttest the three active treatments appeared equally effective. However, at a 6-month follow-up. BE couples showed signs of relapse, whereas both CPT and CO couples seemed to maintain their treatment gains. This component analysis is important for a number of reasons. First, given the multifaceted nature of BMT. clinicians need to know which ingredients are accounting for its effects. Second, the analysis allows us to begin identifying the change mechanisms in BMT. Each procedure is expected to produce particular types of changes at particular rates. By comparing these components with one another and with the total treatment package, one can evaluate the extent to which BMT *PortIons of this manuscript were presented Philadelphia. Penn.. November 1984.
at the Meet.
of the Association
549
for
the Advancement
of Behavior
Therapy,
550
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works for the reasons hypothesized by its leading theorists. In particular. it was predicted that BE would produce relatively strong immediate effects, with its emphasis on immediate behavior change, but not much was expected in the way of continued improvement subsequent to termination. Moreover. relapse rates were expected to be higher in this condition than in the other two, since BE deemphasized prevention. In contrast. CPT couples were expected to show relatively weak immediate effects, but whatever effects were obtained were expected to be maintained. Moreover, since much of CPT is devoted to encouraging the application of conflict-resolution skills subsequent to therapy, there was some expectation that CPT couples would continue to change for the better after posttest. Finally, CO couples were expected to receive the best of both worlds. The BE component should produce strong immediate effects, while the CPT component was expected to lead to the maintenance of these changes. The purpose of the present study was to evaluate the long-term effects of these three treatments, by collecting data from couples 1 yr after treatment te~ination. Data are reported on 43 couples who had been randomly assigned to and completed one of the three treatments. METHOD
Subjects There were 60 couples who completed BMT in this study: 43 who were treated and 17 assigned to a waiting-list control (WLC) group. Fifty-seven of the 60 couples were married, and all were living together throughout their participation in the project. Couples were offered treatment unless they met one or more of the following exclusionary criteria: a primary complaint of sexual dysfunction or disorder (not including disorders of sexual desire; n = 7): current severe alcohol abuse (n = 1); an acute psychotic episode (n = 2); incapacitating current physical problems which precluded active participation in marital therapy (n = 3); or a current episode of spouse abuse (n = 2). In addition, two couples were refused treatment because they were not distressed, based on our assessment criteria. Out of 67 couples assigned to a treatment condition, 77 dropped out prior to completing the treatment program: 2 couples in each of the three treatment conditions; and 1 WLC couple. Therapists The therapists were four psychology graduate students in training and one masters-level counselor. All treated at least 1 couple in each condition. Excluding the 17 WLC couples, the number of couples treated by each therapist varied from 3 to 16, with a mean of 8.6. Follow -up measures Dyadie A~usiment Scale (DAS; Spender, 1976). The DAS is a widely used self-report questionnaire serving as an index of global marital adjustment. It is commonly used in marital therapy outcome studies and has good psychometric properties (cf. Jacobson. Elwood and Dallas, 1981). Areas of Change questionnaire (AC; Weiss and Perry, 1979). The AC was used to assess the effects of treatment on couples presenting complaints. Part A consists of 34 common marital behaviors and requires that each spouse rate, on a 7-point Likert scale, how much behavior change is desired for each behavior. For example, one item on the AC is “I want my partner to pay attention to me”. Possible endorsement can vary from - 3 (much less often) to + 3 (much more often). When no change is desired the item is rated ‘0’. The AC has been shown to disc~minate between distressed and nondistressed couples (Margolin, Talovic and Weinstein, 1983) and to discriminate between couples responsive and unresponsive to BMT (Baucom, 1982). Part B, which asks both spouses to estimate the amount of behavior change which their partners want from them, was not included in this study. Two measures were derived from the AC. One is simply the total score for part A, which requires adding the absolute Likert values across all items. This is a common scoring procedure (Margolin et al., 1983), and simply reflects the total amount of behavior change desired. The second measure was the percentage of problem reduction (“,/,R). This measure reftected the percentage of presenting complaints where less change was desired at posttest (or at follow-up) than at pretest. For example, if a spouse desired ‘much more’ attention at pretest but only ‘somewhat more’ at posttest, this problem was rated as reduced at posttest.
A component analysis of behavioral marital therapy
551
Procedure Assignment to treatment condition was random. Each couple was seen for 12 treatment sessions, with the option of extending to 16 if the therapist felt that such an extension was clinically indicated. Prior to this treatment regimen, all couples received two assessment interviews in which pretest measures were administered, and a roundtable discussion where they were informed of the treatment condition to which they had been assigned. All posttest procedures were readministered by a research assistant 2 weeks following the final therapy session. Six months and 1 yr following the posttest, separate packets were mailed to each spouse. Included in each packet was a request for a completion of follow-up questionnaire, the questionnaires themselves and a stamped return envelope. The content of each treatment condition is described in the initial report (Jacobson, 1984b). The treatment manual for the project was the Jacobson and Margolin (1979) book, supplemented by more recent clinical innovations (Jacobson, 1984a).
RESULTS Pretreatment characteristics
c2fcouples
Demographic characteristics. Couples in the various treatment conditions were compared on relevant demographic variables, including age (for both spouses), education level (for both spouses), duration of marriage and number of children. The multivariate analysis of variance (MANOVA) failed to indicate statistically significant differences between groups on these demographic measures. Husbands averaged 38.8 yr of age, whereas wives averaged 36.1 yr. Males averaged 15.8 yr of education, and females 15.2 yr. The average marriage duration (or length of time living together in the case of unmarried couples) was 9.7 yr. Couples averaged 1.2 children/family, with one-third of the couples childless. Pretreatment dtflerences on criterion measures. The pretest means for all treatment conditions on each dependent variable are shown in Table 1. To evaluate whether or not the groups were significantly different at pretest, a MANOVA was conducted. It provided no evidence for group differences prior to treatment. Summary
qf immediate treatment eflects
The results for this updated sample of 60 were virtually identical to those originally reported (Jacobson. 1984b). All groups were significantly more effective than no treatment at all, but they were virtually indistinguishable from one another on all criterion measures. The only distinctions to be made between the three active treatments were on measures designed primarily as
Table
I. Pretest.
posttest
and
follow-up
scores on the DAS. condition
DAS Group
AC and
:
AC
“/,Ra
Pre
Post
FUI
FU2
Pre
Post
FUl
FU2
Post
FUI
FU2
90.9 13.6 14
103.5 12.0 14
94.9 12.4 14
93.0 18.4 I4
24.6 1.4 I4
16.9 6.8 14
20.2 7.8 12
20.9 12.3 14
0.49 0.15 I4
0.41 0.1 I 14
0.43 0.21 12
86.9 IO 7 I4
97 5 14.7 I4
97.1 13.0 I4
92.1 14.3 I2
27.5 8.2 I4
14.7 7.3 I4
17.7 8.1 14
21.9 9.1 13
0.54 0.19 14
0.59 0.13 IO
0.53 0.18 7
86.0 13.3
15
99.3 12.4 IS
101.9 13.8 1s
98.4 18.5 13
29.8 10.9 I5
20.3 9.9 I5
21.6 14.2 15
19.0 10.6 I?
0.48 0.14 15
0.56 0.17 13
0.48 0.1 I II
95.9 13 b 17
94.2 15.0 I7
25.1 11.2 lb
22.9 11.6 I6
BE 8
SD h CPT .\’ SD z CO
.i SD .z H.LC .T SD .?!
All scores are for couples (hushand.and for the WLC group “Pretest score omitted because posrtest
wife scores combined). and follow-up
0.37 0.17 I6 Follow-up
scores are adjusted
data were not collected based on pretest
score.
552
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S. JACOBSON; et al.
manipulation checks. Thus, as described in the earlier paper. BE couples showed greater increases in the frequency of positive behavior exchanged at home than did couples in other conditions. based on the Spouse Observation Checklist (SOC). The SOC is a checklist of pleasing and displeasing behaviors which spouses complete at home. The results were based on 14 days of data collection prior to therapy and 14 immediately following therapy. Groups were also compared immediately after therapy on an observational coding system developed in the laboratory, the Dyadic Interaction Coding System (DICS). The DICS was developed to code the quality of emotional responsiveness and conflict-resolution skills of spouses when engaged in direct interaction with one another. All couples engaged in IO-min problemsolving discussions before and after therapy, based on identified conflict areas in their own relationship. These interactions were videotaped and later coded by a research assistant who was blind to both treatment condition and time of interaction. After observing the entire IO-min interaction, the coder rated each spouse on the following dimensions: affect (AF); attention (AT); acceptance of responsibility (AR); side-tracking (ST); willingness to change (WC): and quality of agreement (QA). Reliability was determined in a number of different ways: percentage agreements between raters ranged from 0.70 to 0.81, with a mean of 75.4%; K-values ranged from 0.56 to 0.79. with a mean of 0.654; correlation coefficients range from 0.57 to 0.93, with an average coefficient of 0.735. Preliminary normative research on the DICS indicates good discriminant validity, with nondistressed couples exhibiting better performance on five of the six codes (all except WC) than their distressed counterparts. The DICS was designed to measure both emotional responsiveness and problem-solving skill using a cost-effective method. It was used to see whether or not couples who received CPT learned the skills that were taught in that condition. Any change on these measures from pre- to posttest in BE couples would be an indirect consequence of an improved relationship, since these couples were not taught problem-solving skills. WLC group couples showed no improvement on any of the measures and actually deteriorated to a significant degree on AF [t(16) = 3.00, P < 0.051 and AR [t(16) = 3.00. P < 0.051. Couples receiving CPT showed significant improvement in AF [t(13) = 3.00, P < 0.051. and QA [t(13) = 3.00, P < 0.051. Interestingly, significant improvement was evident only in the CPT condition. For planned comparisons looking at differences between groups on the DICS. composite scores were used, derived by adding together the scores on all six measures. The basic finding for this composite score was the same as it was for other measures: all groups improved significantly more than the WLC, but the three active treatments were indistinguishable from one another. Summary
of 6-month
follow-up
(FUl)
Some follow-up data were available for all treated couples.* The means and standard deviations on all follow-up measures are presented in Table 1. On all three follow-up measures. BE couples showed deteriorations at FUl. In contrast, as a group both CPT and CO couples tended to maintain or enhance their treatment gains. To directly compare differences between groups at FU 1, planned comparisons of greatest interest were examined: each involved a comparison between CO and one of the two components. For measures of marital satisfaction (DAS) and presenting problems (AC), the comparisons were based on analyses of covariance, with pretest scores used as covariates. For the Oj,R measure, the comparison was based on arcsin transformed proportions
‘For
some analyses (those reported in Tables 2 and 3). couples who chose not to report follow-up data because they were separated at either FIJI or FU2 were counted as ‘unimproved’. Thus, couples were not removed from Tables 2 and 3 when they failed to report data due to separation or divorce. Moreover, in a few cases couples failed to return written questionnaires but were willing to allow administration of the DAS by phone interview. Data obtained by telephone were included in Tables 2 and 3. Finally, instead of excluding separated or divorced couples from between-groups comparisons, these couples were e-/en included in the analyses even when they failed to report data. In instances where data were not reported due to sepamtton or divorce. either the pretest score or posttest score was subsutured for the mrssmg follow-up score. The rule was that whtchever score was lower would be used as the follow-up score in the event that the data were not reported. This seemed to be a conserative practice which could in no way be viewed as self-servtng. Excluding such couples from the analysis would have clearly Inflated the success rate of the treatment in question In an artifcial manner.
A component
Table 2. Treatment
oroeress
Posttest
Groun
N
Enhancemenr
BE CPT CO
14 I4 15
0 21.4(14.3) 33.3 (26.7)
Total
43
1X.6(14.0)
analysis
from oosttest
of behavioral
marital
553
therapy
to FUI. and FUI to FU2. based on the DAS
FUI to FU2
to FUI Deterioration
N
Enhancement
No chance
28.6 64.3 46.7
71.4 (35.7) 14.3 20.0(13.3)
14 I2 I3
21.4(14.3) 0 15.4
50.0 66.1 53.8
46.5
34.9 (20.9)
39
12.8(10.3)
56.4
No channe
Each number reflects the percentage of couples corresponding to the status represented by the particular numbers m parentheses represent the percentage ol couples whose changes were clinically significant, dllked from the overall enhancement or deterioration rate.
Deterioration 28.6 (21.4) 33.3 30.8 30.8 (28.2) column heading. The when that percentage
the percentage of problems identified at pretest that were reduced at the time of FUl. For both measures of marital satisfaction [t(44) = 2.45, P < 0.021 and the percentage of problems reduced [t (36) = 2.13, P < 0.041, CO couples reported significantly more improvement than did BE couples. reflecting
One -J’r folloiz,-up
(FU2)
Changes between FUl and FU2. The process of improvement and deterioration in couples between FUl and FU2 might be best ascertained by examining Table 2. This table shows the relapse rates in each condition during the first and second six-month periods following the end of therapy. as well as the proportions whose relationships were enhanced and maintained during those periods. During the first 6 months following termination, the relapse rates were significantly higher among BE than among CO couples, and a significantly higher proportion of CO couples continued to improve significantly during the course of the 6-month period (Jacobson and Follette, 1985).* In contrast. between FUl and FU2 the groups deteriorate and improve at relatively comparable rates. Almost one-third of the treated sample shows some deterioration during this 6-month period. Relatively few couples improved significantly during the 6-month pericd. However, whereas none of the BE couples improved during the first 6 months following the end of treatment, 1 out of 5 improved between FUl and FU2. In short, while the course of change during the first 6 months was in accord with the predictions, with BE couples at greatest risk for deterioration and CO couples holding their own, this trend did not continue during the second 6 months following the end of therapy. Moreover, substantial proportions of couples in all treatments deteriorated during the second 6-month period. and this deterioration exceeded the rate of improvement during this period. Status qf couples 1 -yr following therapy. Table 3 reports the proportions of couples who are improved. no longer distressed, deteriorated and separated or divorced at posttest, FUl and FU2. At the time of FU 1, the proportions of both improved and ‘no longer distressed’ couples were significantly higher in the CO condition than in the BE condition (Jacobson and Follette, 1985). By the time of FU2. the differences in improvement rates between groups are no longer statistically significant. Slightly more than one-half of the couples across the entire sample remain improved at FU2 compared to pretest. Improvements were clinically significant for slightly more than one-third of the entire sample. It should also be noted that a fifth of the sample was either divorced or had separated at least once by the time of FU2. These separations and/or divorces were confined exclusively to BE and CPT couples.? CO couples were significantly less likely to separate than either BE (z = 1.77, P < 0.05) or CPT (z = 2.49. P < 0.01) couples.
*The rehable change mdex (Jacobson. Follette and Revenstorf, 1984) was used to determine what proporttons of couples in each condition deteriorated or progressed during the follow-up periods. For those couples who had deteriorated, the deterioration was deemed climcally significant if their status at the time of the follow-up placed them closer to the mean of the distressed than the nondistressed population. For those couples who showed statistically significant improvement during the course of the follow-up period. clinically significant improvement was inferred when their follow-up score placed them closer to the mean of the nondistressed than the distressed population. tone CO couple had decided to separate after therapy but remain lovers in a monogamous relationship. This couple was unmarried and had been living in a communal household at the time they entered therapy. Their decision to live apart was not a separation in the sense that the term is usually used; rather, it was an affirmattve decision that their relationship would be better if both had their own residences. Since all other factors indicated clinically significant improvement. thts couple was not considered a casualty.
554
NEIL S. JACOBSON et al.
Table 3. Percentages
of couples
Improved.
no longer
distressed
(ND). determrated
Posttest Gr0Llp
,V
BE CPT co WLC
14 14 15 I7
Total”
43
Follow-up data “Totals exclude bData wadable ‘Data available
ND
Determrated
SD
.V
85 7 71.4 60.0 I7 6
78.6 57.1 40.0 11.8
7.1 0 0 23.5
0 0 0 0
14 I4 15
72. I
58. I
2.3
0
43
Improved
were WLC from from
not collected couples. 13 couples. 40 couples.
and separated
or divorced
Improved
(S DI based on the DAS FL?
FIJI ND
Detervxared
SD
.V
Improved
ND
42.9 64.3 80.0
28.6 57. I 60.0
14.3 0 0
71 28.6 0
I-l I2 I3
42.9 50 0 61.5
28.6 25.0 53 8
Determrated I4 3 0 77
21 -1 38 4’ 0
S D
62.8
48.9
4.7
11.6
39
51 2
35.9
77
20.0
for WLC couples.
of correlated means were used to calculate the Changes within groups over time. t-Tests significance of changes at the group level. The means and standard deviations of these group changes are depicted in Table 1. The Bonferroni procedure was used to correct for the calculation of multiple t-tests. Within group t-tests show significant deterioration among BE couples during the follow-up period on marital satisfaction [t(13) = 2.96, P < 0.011. In contrast, no significant deterioration occurs at the group level for either CPT [t(ll) = 1.26, NS] or CO [t( 12) = 0.40, NS] couples. As a result of deterioration, BE couples are no longer significantly better off than they were when they came into therapy on either the DAS [t( 13) = - 0.58, NS] or the AC [t (13) 1.24. NS]. In contrast, both CPT and CO couples remained improved on both measures relative to their scores at pretest: for CO couples, improvement remained significant on the DAS [t( 12) = - 2.60. P < 0.051 and on the AC [t( 11) = 4.76, P < O.OOl]; similarly, for CPT couples improvement remained significant on both the DAS [t(ll) = -2.08, P < 0.051 as well as the AC [t(12) = 2.27, P < 0.051. Between-groups comparisons. The same planned comparisons used during the FUl were employed at FU2. At this time, none of the group comparisons showed statistically significant differences. In other words, analyses of covariance, based on scores at FU2 with pretest scores used as covariates, failed to uncover differences between the treatments. This failure was repeated with the percentage problem reduction measure. Thus, group comparisons revealed that the significant differences in favor of CO relative to BE that had been found at FUl were no longer evident by the time of FU2. DISCUSSION The updated summary of the immediate treatment effects reported here substantiates the findings in the earlier report (Jacobson, 1984b). BMT, in whatever form, produced significant changes in couples relative to a control group, but immediately after therapy the three versions of BMT were not differentially effective. This updated report also strengthens the 6-month follow-up trends reported in the earlier paper. BE couples showed alarmingly high deterioration rates, while not a single couple in this condition significantly enhanced their marital satisfaction during the first 6 months following treatment termination. In contrast, CPT and CO couples showed relatively low deterioration rates, and almost a third of the couples in these two treatments significantly enhanced their marital satisfaction during the follow-up period. These within-group trends were also reflected in the comparisons between groups and in the proportions of couples who remained improved in each condition at the time of FUl. These differences were in accord with predictions. Thus. at the time of FIJI, it looked as if the skill training emphasis in CPT was paying off. This component appeared to be necessary for the maintenance of treatment gains. However, CPT did not appear to be sufficient in and of itself, given the high separation/divorce rate among CPT couples. The absence of significant differences between groups on most measures at FU2 suggests that the superiority of CO is temporary. There was some evidence of deterioration even in this condition during the second 6 months following therapy. It may be that the combination of BE and CPT provides couples with a temporary boost relative to an exclusive focus on immediate change, but by the time 1 yr has past other factors in the lives of the couple become more salient than the experience in therapy. If this interpretation is correct, one would expect continuing convergence
A component analysis of behavioral marital therapy
555
between the three treatments during the second year following termination. A 2-yr follow-up is currently underway to investigate this possibility. It should be pointed out, however, that even at FU2 there was some evidence for the superiority of the CO treatment. Even after the fairly substantial relapse that occurred between FIJI and FU2, CO couples reported significant improvement on all measures relative to pretest, whereas this was not the case for the BE treatment. CO couples also produced by far the highest percentage of nondistressed couples at the time of FU2. Finally, none of the CO couples had split up as yet, a fairly remarkable statistic. In short, the great majority of CO couples were improved relative to when they entered therapy; a majority of them had improved their relationships fairly dramatically; and none of them had split up. As has already been mentioned, one possibility suggested by these data is that even a skill-o~ented maritai therapy has benefits which are only temporary. Perhaps no matter how initially potent marital therapy is, its influence does not extend beyond an initial period of skill utilization. It is possible that booster sessions would extend the effects of therapy further in time. The idea that a brief time-limited treatment program is a permanent solution to long-standing relationship problems may be naive. The traditional model of discrete intensive treatment periods followed by termination may be insufficient to produce long-term improvements in marital intimacy. Perhaps a more appropriate model to be tested in future research involves the therapist as a consultant (more like a dentist or accoun~nt): once a relationship between the therapist and couple is formed, they come together periodically to work on relationship issues. Above and beyond the issue of maintenance, it is also apparent from the clinical significance data that substantial proportions of couples are not helped at all, even in the CO condition. For these couples, current BMT treatment does not seem applicable. Several lines of research have the potential to look more closely at these apparent limitations of BMT. First, BMT could be evaluated in studies using more experienced therapists, under treatment conditions that are less constrained by typical research considerations. Second, treatment failures could be intensively analyzed (Barlow, Hayes and Nelson, 1984). Third, attempts could be made to integrate BMT with other approaches. Acknowledgemenrs-This research was supported by Grant No. 2 ROl MH 33838-04 from the National Institute of Mental Health. awarded to N. S. Jacobson. Special thanks are due to therapists Kathy Melman, Lisa Wood, Debbie McDonald and Bob Berley; and to research coordinators Carolyn Phelps, Nicole Bussod and Christy Crose. Requests for reprints should be addressed to N. S. Jacobson.
REFERENCES Barlow D.. Hayes S. and Nelson R. (1984)The Scienrisr Practitioner: Research and Accountubility in Clinical und Educarianal Setrings. Pergamon Press. New York. Baucon D. H. (1982) A comparison of behavioral contracting and problem-solving/communications training in behavioral marital therapy. Behav. Ther. 13, 162-174. Jacobson N. (1984a) The modification of cognitive processes in behavioral marital therapy: integration of cognitive and behavioral intervention strategies. In Ma&al Znteracrian: Ana~_vsisand Modification (Edited by Hahlweg K. and Jacobson N.). pp. 285-307. Guilford Press, New York. Jacobson N. (1984b) A component analysis of behavioral marital therapy: the relative effectiveness of behavior exchange and problem solving training. J. consult. cl&. Psvehoi. 52, 295-305. Jacobson N. and Follette W. (1985) Clinical significance of improvement resulting from two behavioral marital therapy components. Be&au. Ther. In press. Jacobson N. and Margolin G. (1979) Mariral Therapy: Strategies Based on Social Learning and Behavior Exchange Principles. Brunner’Mazel. New York. Jacobson N.. Elwood R. and Dallas M. (1981) Assessment of marital dysfunction. In Eehauioral Assessmenr of Adult Duorders (Edited by Barlow D.). Guilford Press. New York. Jacobson N.. Follette W and Revenstorf D. (1984) Psychotherapy outcome research:. methods for reporting variability and evaluating clinical significance. Beirar. T’er. 15, 336-352. Margoiin G.. Taiovoc S. and Weinstein C. (1983) Areas of change questionnaire: a practical approach to marital assessment. J. cotlsuli. rh. Ps,l+chol. 51, 920-93 1. Spanier G. (I 976) Measuring dyadic adjustment: new scales for assessing the quality of marriage and similar dyads. f. Murr. Fon7. 38, 15-28. Weiss R. L. and Perry B. ( 1979) Assessment and Treatmenr of Muriral Dwfuncrion. Oregon Marital Studies Program, Eugene Oreg. (Write to R. L. Weiss. Department of Psychology. University of Oregon, Eugene, OR 97403.)