Behavioral martial therapy outcomes: Alternate interpretations of the data

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21, 129-138, 1990

Behavioral Marital Therapy Outcomes: Alternate Interpretations of the Data ANITA IVERSON

DONALD H. BAUCOM Umverszty of North Carolina at Chapel Hill The data from a behavioral marital therapy outcome study were analyzed in order to better understand the phenomena involved when spouses improve in their communication skills but do not improve in marital satisfaction. Three possible patterns of marital therapy outcome for the subset of subjects who improved in communication skills hut not in marital satisfaction were proposed: (a) spouses who denied their distress at pretest, obscuring any subsequent improvement in marital adjustment ratings; (b) spouses who did not effectively apply their acquired skills to problem content areas in the marriage; and (c) spouses who made a thoughtful, positive decision to end the marriage. The first two of these three proposed patterns were present among the distressed couples being studied.

Investigators of behavioral marital therapy (BMT) have demonstrated consistently that intervention results in specific skill acquisition (e.g., communication changes) and improvement in marital adjustment for many couples (see Baucom & Hoffman, 1986, for a recent review). Although there is evidence that treatments focusing solely on communication training and problem-solving result in increases in marital adjustment for some couples (e.g., Baucom, 1982; Emmelkamp, van der Helm, MacGillavry, & van 7anten, 1984), little attempt has been made to clarify whether the degree of increase in marital adjustment is correlated with the degree of change in communication. This is important because behavioral researchers postulate that improvement in communication and problem-solving skills leads directly to increases in marital adjustment. Indeed, communication is the most frequently cited problem for clinic-referred couples (Geiss & O'I eary, 1981). In addition, a large body of literature confirms that distressed couples differ from nondistressed couples in their frequency of negative communication and their patterns of communicating (see Baucom & Adams, 1987, for a recent review). Thus, clarifying whether acquiring comPreparation of this article was supported in part by National Institute of Mental Health Grant #37118 to Donald H. Baucom. Requests for reprints should be sent to Donald H. Baucom at the Department of Psychology, CB #3270, Davie Hall, University of North Carolina, Chapel Hill, North Carolina 27599.

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Copyright 1990 by Assodttlon for Advancementof Behavior Therapy All rights of t~production in any form r~e~ved.

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munication skills is sufficient to increase a couple's satisfaction with the marriage is critical. The current investigation had two foci: (a) to investigate the extent to which acquiring communication skills in BMT is correlated with increases in marital adjustment, and (b) to delineate types of spouses who demonstrate improved communication skills without corresponding increases in marital adjustment. Consistent with clinical observations, three types of spouses were anticipated who would demonstrate an improvement in communication and problemsolving skills without significant increases in reported marital satisfaction. First, some spouses might be defensive at pretest and fail to acknowledge legitimate concerns, thus resulting in initial elevated adjustment scores. This denial of presenting concerns before therapy begins is likely to obscure any beneficial effects that treatment may have on subsequent measures of marital adjustment. Consequently, for this group of spouses, their initial response set of denying concerns (as measured by a marital social desirability scale) can result in misleading conclusions that treatment has not been of assistance. This might occur despite improved communication skills that suggest that these spouses may be more functional within the relationship at posttest. Second, some spouses might have acquired communication skills during therapy, but might have had insufficient opportunities to resolve many of the content problems within the marriage. In most marital treatment outcome investigations, therapy is limited to 8 to 12 sessions. For some couples with numerous or complex presenting complaints, this might be an insufficient amount of time to deal adequately with their concerns. In essence, therapy has been terminated prematurely for these couples. Third, some spouses might have acquired the skills, addressed issues of concern, and concluded that they are not happy in the relationship. Based on this conclusion, these couples might make a thoughtful, informed decision to terminate the marriage. The major purpose of this study is to clarify whether there is empirical support for the existence of the three types of spouses described above, who have demonstrated an improvement in communication skills but not in marital adjustment. Exploring this phenomenon is important because communication skills are a central component of a wide variety of marital treatment programs currently in use. Increased understanding of these subgroups of spouses will provide the opportunity to tailor future treatment programs to better meet their needs. In addition, knowledge about these types of spouses will facilitate more effective evaluation of the results of treatment outcome studies. For example, spouses who have minimized their marital distress at pretest may have benefited from treatment, but any treatment effects may be obscured by the subjects' initial denial. In such cases, statistical adjustments for initial denial might assist in evaluating the effects of the treatment program.

METHOD

Subjects Forty-eight maritally distressed couples who participated in a marital therapy outcome investigation were included in the current study. The wives averaged

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31.7 years of age and 15.6 years of education. The husbands averaged 33.6 years of age and 17.3 years of education. The outcome project was designed to investigate the utility of supplementing behavioral marital therapy (BMT) with cognitive restructuring (CR) and emotional expressiveness training (EET) (Baucom, Sayers, & Sher, 1988). Couples were randomly assigned to one of three therapists and one of four treatments for 12 weeks of skills-oriented marital therapy. All couples received a minimum of six weeks of problem-solving and communication training as the BMT component of their therapy. Couples receiving BMT alone had additional behavioral marital therapy, again focused on problem-solving and communication training, for the other six weeks of therapy. Couples receiving CR + BMT had six weeks of CR followed by six weeks of BMT. Couples receiving BMT + EET had six weeks of BMT followed by six weeks of EET. Finally, couples receiving CR + BMT + EET had three weeks of CR, followed by six weeks of BMT, followed by three weeks of EET. In addition to the therapy sessions, couples were asked to practice their skills on a nightly basis between sessions. For a more complete description of CR and EET see Baucom et al., 1988. All four treatments were more effective than a wait list condition, but there were no significant differences among the active treatment conditions in promoting change on the various measures described below (Baucom et al., 1988). Therefore, the data were collapsed across treatment conditions for the current investigation.

Measures Global Distress Scale (GDS, Snyder, 1981). Overall marital adjustment was assessed using the GDS from the Marital Satisfaction Inventory (MSI) (Snyder, 1981). This scale is composed of 43 items that are clustered into two dimensions: (a) general unhappiness in the marriage, and (b) uncertain commitment to the relationship. For this study, the total of these two subscales was used.

Marital Interaction Coding System Ill (MICS-III, Weiss& Summers, 1983). The MICS is the most widely used observational system for evaluating couples' interactions and has consistently demonstrated changes in couples' behavior following BMT. Videotaped observations of the couples engaging in two sevenminute problem-solving interactions were coded for the amount of negative communication from each spouse prior to therapy. Negative communication has been found consistently to differentiate maritally distressed from nondistressed couples, whereas positive communication is not consistently a significant discriminator. Therefore, decreased negative communication was selected as the index of improved communication skills in the present study. Negative communication for this study is the sum of the two major negative summary codes from the MICS-III, blame and invalidation. Blame is composed of complaining, criticizing, assuming one's partner has a negative attitude, and putting down one's spouse. Invalidation includes disagreeing, denying responsibility, making excuses for one's behavior, nonverbal interrupting, nonverbal noncompliance, and nonverbal gestures that communicate disgust or disapproval. ' i The MICS-III was codedat the Universityof Oregon under the directionof Robert Weiss, who created the MICS. Coding with the MICS-III requiredthat coders continuallycalibrate

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Areas of Change Questionnaire (AC, Weiss & Birchler, 1978). The AC is a behaviorally oriented self-report measure o f spouses' requests for behavioral change from their partners. It focuses on 34 specific aspects o f marital interaction that address the span o f potential problematic content areas in the marriage. Weiss, Hops, and Patterson (1973) |eported an internal consistency index o f .89 for the AC. Conventionalization Scale (CNV, Snyder, 1981). The Conventionalization scale from the MSI contains 21 items that reflect the tendency o f spouses to report on the marriage in socially desirable terms. This validity scale reflects denial o f even minor marital difficulties and a portrayal o f the marriage in an unrealistically positive way. The CNV is composed o f three dimensions: (a) reports o f a perfect marriage, (b) reports o f a perfect mate, and (c) denial of considerations of marital alternatives. Examples from this scale include items such as, "Every new thing I have learned about my mate has pleased me." and, "We are as well adjusted as any two persons in this world can be-" Snyder's scale is a shortened version o f the marital conventionalization scale developed by Edmunds (1967). Edmunds provides validation for his scale as an index o f the tendency to distort self-reports o f marital satisfaction in the direction o f social desirability, including correlational evidence between the conventionalization scale and the Lie Scale from the MMPI, (r = .44). Snyder reports that moderate scores (45-60T) on his CNV scale are infrequent among individuals entering marital therapy, and indicate a reluctance to disclose marital difficulties (Snyder, 1981). Only 13o7oo f couples entering marital therapy score above this cut-off score. Couples'Perceptions of Therapy Questionnaire (CPT~_j. This questionnaire was developed for the current investigation to assess each spouse's perceptions o f the effects o f therapy on their relationship. Spouses were asked about their perceptions o f the helpfulness o f therapy (from Very Destructive to Very Helpful). In addition, partners reported their plans concerning continuation o f the marriage and the impact that therapy had on this decision. In order to minimize any tendency to provide socially desirable responses on this questionnaire, research assistants handled this phase o f the data collection, rather than allowing couples to have direct contact with their therapist when providing this information. Further, the couples were assured o f their anonymity in providing answers to the questions. Finally, the questionnaires were completed in the couples' homes, rather than in the treatment setting. Procedures Except for the CPTQ (which was given only at posttest), the variables described above were gathered both prior to and at the termination o f therapy.

with a master coder to insure fidelity of coding. A random sample of approximately25% of the tapes were double-coded, and if any tape did not meet the standard of at least 90°70 agreement of the two coders on a code by code basis, the tapes were recoded. Unfortunately, information is not available from the University of Oregon to calculate kappa coefficients, but the level of agreement required of coders is quite high.

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All spouses were mailed the self-report measures before and after treatment and were instructed to complete them independently o f each other. During the initial assessment procedure at the clinic, each couple attempted to resolve two moderate size problems in their relationship. These interactions were coded with the MICS-III. A similar procedure was employed one week following the termination o f therapy.

RESULI S Formation of Groups The above measures were used to define the three subgroups of spouses proposed. The criteria for all groups require that these spouses have improved in their communication skills (by significantly decreasing their negative communications on the M I C S - I I I ) but have not significantly increased in their report of marital satisfaction (as measured by the GDS). Significant change was calculated using the Reliable Change Index developed by Jacobson, Follette, and Revensdorf (1984) and revised by Christensen and Mendoza (1986). The Reliable Change Index focuses on the standard error o f difference scores, such that significant change for an individual requires change beyond what would be expected by chance, given the instability o f the measure. Jacobson and Revensdorf (1988) proposed that, when normative data are not available for a given measure, the Reliable Change Index be employed by requiring approximately two standard errors o f change on that measure. Given that normative data for two o f the three measures being used in the present study are not available, this strategy for the Reliable Change Index was employed consistently across measures. 2 The first group includes those spouses who appear to have denied marital difficulties at pretest. This initial denial results in artificially elevated adjustment scores that might mask subsequent improvements in marital functioning. In addition to meeting the above requirements on the Reliable Change Index for the M I C S - I I I and GDS (i.e., improved communication skills but no significant increase in marital satisfaction), the "deniers" are defined here as spouses who have a pretest Conventionalization (CNV) score above the cutoff(45T) for couples entering marital therapy. Snyder (1981) reports that CNV scores at or above 45T in this population are infrequent and indicate a reluctance to disclose marital difficulties. The second group includes spouses who fit a pattern in which therapy has been prematurely terminated, thus not allowing these partners sufficient opportunity to adequately address and resolve problematic content areas in the relationship. In addition to meeting the criteria on the M I C S - I I I and GDS, these spouses demonstrate no significant decreases in requests for behavioral 2 The criteria for group formation are based on each spouse's set of scores separately, rather than on both spouses as a couple. For example, because one spouse initially denies problems does not mean that the other spouse denies also. Similarly, one spouse might be planning to divorce the partner without having discussed this with the partner. Again, this does not necessitate that the partner also be planning to divorc~

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change f r o m their partners (AC). However, they report on the C P T Q that therapy has been helpful overall, because they are m a k i n g progress. In addition, these spouses are within the n o r m a l range for couples entering therapy on the C N V (below 45T) and are not planning to divorce (as indicated on the CPTQ). The third g r o u p includes those partners who, in addition to meeting the Reliable C h a n g e requirements on the M I C S - I I I and GDS, are planning to divorce (as indicated o n the CPTQ). However, they do report that therapy has been helpful in m a k i n g that decision (also indicated on the CPTQ). Further, these spouses are within the n o r m a l range for couples entering therapy on the C N V (below 45T). Requirements for inclusion in each o f the groups are summarized in Table 1.

Correlations Between Communication and Marital Satisfaction Changes The first analyses examined the extent to which c o m m u n i c a t i o n skills acquisition is correlated with changes in overall marital satisfaction. Skills acquisition, measured as the decrease in negative c o m m u n i c a t i o n o n the M I C S I I I (including Blame and Invalidation), and marital satisfaction, as measured by the GDS, were correlated, employing a semi-partial correlation in which each posttest score was adjusted for its corresponding pretest score. The correlations between skills acquisition ( M I C S - I I I ) and overall marital satisfaction (GDS) were nonsignificant (males: r = .06, p > .05; females: r = .08, p > .05). In order to examine the possibility that one spouse's marital satisfaction might be related to improvements in the other partner's c o m m u n i c a t i o n skills, semi-partial correlations were also employed to examine this relationship. Each posttest score was adjusted for its corresponding pretest score. Again, the relationship between satisfaction (GDS) and one's partner's skills acquisition ( M I C S - I I I ) were small in magnitude, although one was statistically significant (wives' G D S with husbands' M I C S - I I I : r -- .22, p < .05; h u s b a n d s ' G D S with wives' M I C S - I I I : r = .12, p > .05).

TABLE 1 NUMBEROF SUB~CTSIN EACHMARITALOUTCOI~GROUPANDGROUPCRITERIA

Gender Husbands Wives

Marital outcome groups Group 3c Subjects not accounted for

Group I a

Group 2b

Total

1

2

0

1

4

2

3

0

0

5

a Group 1 criteria: MICS-III < - 1.96 SEO; GDS/> - 1.96 SEo; CNV ~ 45T b Group 2 criteria: MICS-III < - 1.96 SEd; GDS ;~ - 1.96 S•d; AC ~ 1.96 sed; CNV < 45 T; not planning to divorce; rated treatment as helpful c G r o u p 3 criteria: MICS-III ~ - 1.96 SEal;GDS ~ - 1.96 sEd; planning to divorce and rated treatment as helpful for this decision Note. - 1.96 SE is required for the p < .05 significance level for Reliable Change

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Analyses of Subgroups In order to address the lack of correspondence between skills acquisition and increased marital satisfaction, spouses were identified who displayed an improvement in their communication skills from pre to posttest, but did not increase significantly in their marital satisfaction. Change was required at the p < .05 level, using Christensen and Mendoza's (1986) revised Reliable Change Index. Nine (four males and five females) of the 96 spouses met these criteria. This is a rather small sample, but it is an important group to consider in order to understand differential responses to treatment. Within this subset of spouses who improved in skills but did not increase in reported marital satisfaction, individuals were identified who fit one of the three patterns proposed. All but one of the targeted subjects (i.e., 8907o)were accounted for by the denier and premature termination patterns. 3 (There was no relationship between spouses fitting into one of these patterns and the type of therapy that they received.) One out of four husbands and two out of five wives qualified as initial deniers (Group 1). For the premature treatment termination group (Group 2), two of the four husbands and three of the five wives met the criteria. None of the subjects identified as having improved in their communication skills without corresponding increases in marital satisfaction reported plans to divorce at posttest. Therefore, none of these subjects fit the third pattern of marital outcome proposed in this study. No individuals met the criteria for more than one group. There were two couples in which both spouses qualified for membership in the same group, one couple in Group 1 and the other in Group 2. Spouses of the remaining group members did not qualify for inclusion in any of the three groups.

DISCUSSION The current results demonstrate little relationship between improvement in communication and improvement in relationship satisfaction. A small number of subjects in the present study exhibited improved communication skills without a corresponding increase in marital adjustment (9 out of 96 at the p < .05 significance level for reliable change). Given this small sample, all conclusions based upon these findings must be viewed as tentative. However, when this phenomenon is present, the patterns of marital outcome proposed by this study can account for the great majority of these spouses (8907o).

3 Based on Jacobson and Revensdorf's (1988) discussion of the Reliable Change Index, setting the requirement for change at the p < .05 might be unnecessarily stringent. Therefore, additional ~n~lyses were conducted in which the criteria cut-offs were broadened to include subjects who were less extreme but conceptually similar. At the p < .10 significance level, 82% of the spouses identified as improving in communication skill% but not in marital satisfaction, were accounted for by Groups 1 and 2. At the p < .20 significance level, 83% of the subjects can be described by the patterns proposed. These analyses indicated that the patterns of group inclusion were consistent across the three significance levels (p < .05, .10, and .20).

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Only a small number of the subsample of spouses qualified as initial deniers of marital difficulties at pretest. This low base rate is inherent in the way this category was defined. The cutoff score required on the Conventionalization scale characterized only 26~/0 of the current total sample of distressed couples. However, such extreme scores were considered necessary in order to interpret these values as indicative of an invalid response set rather than simply representing genuine happiness in the marriage. Due to the low number of subjects in this category, caution is required in proposing the initial denial phenomenon as a major explanation for why spouses increase in their skills but not in their reports of marital satisfaction. However, such spouses do exist, suggesting that investigators might consider taking this phenomenon into account statistically in future marital treatment outcome research (e.g., by partialing out Conventionalization scores). The largest number of targeted spouses demonstrated a pattern of improved skills, no significant increase in marital satisfaction, and no significant decrease in the amount of behavioral change they requested from their partners. However, these spouses believed that therapy was helpful and were planning to continue in their marriages. One interpretation of this pattern is that therapy had been prematurely terminated for these couples, before they had an adequate opportunity to implement their acquired skills and sufficiently address problematic content areas in their marriage. Although systematic study is necessary to investigate whether additional treatment sessions would have helped this type of couple, recent data are promising. Snyder and Wills (1989) allowed the number of BMT treatment sessions that couples received to vary up to 25, depending on the couples' needs. Consistent with this increased length and flexibility, the number of couples demonstrating reliable improvement on marital satisfaction was higher than in almost all other BMT outcome studies with shorter treatment periods (Baucom & Hoffman, 1986). Snyder and Wills' (1989) findings are consistent with the interpretation that subjects in Group 2 did not have sufficient time to apply the communication skills they acquired to pertinent content areas of their marriage, prior to the termination of therapy. However, there are other possible interpretations of the pattern of scores required for inclusion in Group 2. Although these spouses improved their communication skills, their communication skills might still be inadequate to address issues of concern. Alternatively, these spouses might have acquired the communication skills but might not have applied them outside of the treatment setting. Although differentiating among these interpretations is not possible in the present study, all of the interpretations propose that, in spite of increased communication skills, the spouses have not been able to apply these skills to create behavior changes and increase marital adjustment. None of the targeted subjects met the requirements for inclusion in the third group proposed (spouses who have improved in communication skills but have decided to divorce). The decision to divorce following marital therapy is a very low base-rate phenomenon; only one of the spouses in the total sample present study reported making that decision. Thus, decisions to divorce in spite of skill acquisition does not appear to be a significant factor in explaining why

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couples improve in communication skills but not in marital satisfaction following cognitive/behavioral marital therapy. However, despite the low base rate of this phenomenon, it is one potential outcome of marital therapy and might warrant further investigation. This study proposes three possible patterns of marital therapy outcome that perhaps can broaden our understanding of the process of change involved in marital therapy. Although the data do support the existence of two of these three patterns of response to treatment, this study can only serve as exploratory work in the field. It will be important for future research to establish more clearly the incidence of these patterns in couples receiving marital therapy, using a larger sample. If these patterns can be cross validated or if other patterns emerge, then investigators will be in a more informed position to (a) alter treatments accordingly, and (b) understand more clearly the ways that our current approaches to assessing change can disguise the psychological state of the couple.

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Bellack (Eds.), Behavior therapy in the psychiatric setting (pp. 331-364). Baltimore, MD: William~ & Williams. Weiss, R. L., Hops, H., & Patterson, O. R. (1973). A framework for conceptnaliTing marital conflict, a technology for altering it, some data for analyzing it. In L. A. Hamerlynck, L. C. Hardy, & E. J. Mash (Eds.), Behavior change" Methodology, concepts, and practice. Champaign, IL: Research Press. Weiss, R. L., & Summers, K. J. (1983). Marital Interaction Coding System IlI. In E. E. Filsinger (F_zi.),Marriageandfamily assessment:A sourcebookfor famdy therapy, (pp. 85-115). Beverly Hills, CA: Sage. RECEIVED: July 11, 1989 F~AL ACCEPT~J~CE: October 2, 1989