Treatment of marital distress: Comparing formats and modalities

Adv. Behav. Res. Printed in Great

Ther. Vol. 4, pp. 57-74. Britain. All rights reserved.

Copyright

0146-6402/82/0257-18$09.00/O Q 1982 Pergamon Press Ltd.

TREATMENT OF MARITAL DISTRESS: COMPARING FORMATS AND MODALITIES Kurt Hahlweg*,

Dirk Revenstorfc*,

*Max-Planck-Institut Kraepelinstrasse 10, D-8000 **Universitat Gartenstrasse

and Ludwig Schindler”

fur Psychiatric Mtinchen 40, F.R.G.

Tubingen, Psychologisches 29. D-7400 Tiibingen

Institut 1, F.R.G.

Abstract - In the last decade increasing attention has been paid to the treatment of marital distress. Two approaches have emerged as the most promising because they are supported by some controlled outcome studies: Behavioral Marital Therapy (BMT) and Communication Training (CT). In this experiment these two treatment formats applied in two modalities (C = conjoint, CG = conjointgroup) were compared with each other and with a waiting-list control group. The length of therapy including a behavioral analysis was 15 sessions, with follow-ups conducted after 6 and 12 months. A total of 85 couples were included in the study. To evaluate treatment outcome a multiple assessment battery was used including self report questionnaires and observational measures. Both BMT modalities and Conjoint Communication Training (CTC) showed substantial improvement after therapy when compared to the waiting-list control group whereas couples in CTCG improved on only 1 out of 7 comparisons. When considering the long-term effectiveness, BMT seems to be moderately more effective in stabilizing change than a CT-format.

INTRODUCTION In their review of the existing outcome of research in the field of marriage and family therapy, Gurman and Kniskern (1978) pointed out that there has been a dramatic increase in the number of books, journals, and workshops dealing with marital therapy. The authors located and summarized the results of about 100 studies and concluded that marital therapy in general has positive effects for 65% of the clients. However, many of these studies had serious methodological limitations including for example small sample size, lack of multiple outcome criteria, control groups, and follow-ups. There are two approaches to marital therapy which have emerged as the most promising in the field because they are supported by a number of controlled outcome studies (Jacobson, 1978b): the behavioral and the communication skills approach. As these approaches are the focus of the present study, the major theoretical assumptions and therapeutic components of both will be outlined briefly.

Communication

Skills Training (CT)

Communication difficulties are probably the most common type of problem encountered in couples who seek assistance to improve their interpersonal relationship (Birchler, 1979). A variety of rather heterogeneous procedures focusing on teaching couples to communicate more effectively have been described. The best known are the “Conjugal Relationship Enhancement” (CRE) by Guerney (1977) and especially in Germany the program “Paare lernen Kommunikation” by Berlin (1975). The theoretical basis of these procedures is derived in part from systems theory (e.g., Watzlawick, Beavin and Jackson, 1967) but mainly from Rogerian principles (Rogers, 195 1). All these programs have in common the assumption that a relationship can be enhanced when the following characteristics are present in the communication process (Schindler, Hahlweg and Revenstorf, in press): 1. Each Partner should state his/her own feelings about a problem in a clear, direct, and open way without accusing and blaming the other (self-disclosure, direct emotional expression). JABRT

4:2

- H

57

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K. Hahlweg,

D. Revenstorf

and L. Schindler

2. Each partner should respond to an open and direct statement in a supportive way. He/she should reinforce the speaker and give feedback by active non-verbal listening and verbally paraphrase the content (emphatic responding). 3. Ambiguous and confused communication should be clarified by appropriate statements from the partners (meta-communication). These communication skills are trained with the couples using behavioral rehearsal techniques such as role-playing, coaching, prompting, or modeling. Recent outcome reviews (Jacobson, 1978a; Birchler, 1979) concluded that a structured communication training approach (especially Guerney’s Conjugal Relationship Enhancement) proved to be superior when compared to untreated controls. Unfortunately most of these outcome studies are fraught with serious methodological problems as well. They rely predominantly on analogue populations (normal or only mildly distressed couples), use unvalidated dependent variables and lack follow-up assessment. Therefore it is difficult to draw definite conclusions regarding the short- and long-term effectiveness of CT with moderately or severely distressed couples.

Behavioral Marital

Therapy (BMT)

The theoretical formulations of this approach are based on assumptions from Social Exchange Theory (Thibaut and Kelly, 1959) and Social Learning Theory (Bandura, 1971). The process whereby a happy marriage deteriorates and becomes an unhappy one was described by Patterson and Reid (1970) as a “coercion process” in which both partners use aversive tactics to induce desired changes in their partners. This faulty problem-solving results in a growing rate of unsolved problem areas in the marriage and to a reciprocal increase in aversive reactions by the partners possibly due to habituation mechanisms. An unhappy marriage is then characterized by a low rate of positive reinforcement and a high rate of aversive reactions. Based on these assumptions BMT-intervention strategies include the following components: techniques to increase the reciprocal exchange of positive reinforcement in the couple, communication skills training, and problem-solving techniques including specifying, negotiating, and contracting (e.g., Weiss, Hops and Patterson, 1973; Stuart, 1976; Jacobson and Margolin, 1979). There have been several recent reviews of the outcome of BMT (Jacobson, 1978a; Linehan and Rosenthal, 1979; Revenstorf, Schindler and Hahlweg, in press). According to these reviews the literature on outcome studies can be summarized as follows: 1. BMT (including components such as communication- and problem-solving training) has been shown to be superior to no-treatment and non-specific control groups. 2. BMT seems to be effective with at least moderately distressed couples. 3. The treatment effects are stable over time (follow-ups ranging from 6-18 months). 4. BMT is not more effective than other approaches in the short-term but moderately more effective in the long term. Both treatment approaches have been compared in several studies (e.g., Wieman, Note 2; 0’ Leary and Turkewitz, 1978) but no consistent differences in the effectiveness of BMT and CT have been found. However, the methodological problems mentioned above and the different BMT-treatment strategies used in these studies may have masked possible differences between the two approaches. Also open to experimental investigation is the question of the differential effectiveness of conjoint vs conjoint-group treatment. (BMTstudies used mainly conjoint therapy while CT-studies used a conjoint-group treatment approach.) Given the growing need for marital therapy it seems necessary to evaluate more cost-effective modes of delivery. These two unresolved clinical issues are investigated in the following comparative outcome study. It has to be stressed that the two treatment formats (CT and BMT) do not constitute totally different treatments. In fact, a slightly different communication skills training is used in the BMT-format as well. This research is therefore best conceptualized as a treatment component study, comparing a pure process approach (CT) with a combined process-content approach (BMT).

Treatment

of Marital

Distress

59

Because the results for each format will be published separately (CT: Schindler, Hahlweg and Revenstorf, in press; BMT: Revenstorf, Schindler and Hahlweg, in press) this report focuses on the following questions: 1. Are there any outcome differences between the BMT- and the CT-format using a multiple assessment battery? 2. Are there any differences between a conjoint (C) and conjoint-group (CG) modality? 3. Are the treatment effects stable over time? The design of the study is shown in Fig. 1.

Format

Modality

C

= ConjoInt

BMT

CT

17

16

I coupie I theraplst

CG

= ConJoint

group

16

3 - 4 couples

19

2 WLCG

= waiting

theraalsts

- tist 17

control-group

FIG.

I. Design

of study.

In the cells:

N

of couples.

The couples were assessed on four occasions: At the beginning of treatment, posttreatment, follow up 1 (6 month after therapy = FU 1) and follow up 2 (12 month after therapy = FU 2). The average treatment length was 15 sessions held weekly. Couples in the waiting-list for the control group remained untreated for 3-4 months.

METHOD Selection of Subjects Client couples were recruited through public service announcements on the Bavarian radio station offering treatment for distressed couples (70% of clients) and referrals from mental health agencies and individual clinicians (30% of clients). Couples were accepted for the study if they primarily complained of a distressed relationship rather than a sexual dysfunction, Furthermore, they had to meet the characteristics of 75% of the clients who apply for counselling at German marriage guidance clinics (age: 25-40 years, duration of marriage: l-10 years, middle class; Wahl, 1975). They were excluded if one partner presented with a severe neurotic or psychotic condition. After the initial interview the couples were randomly assigned to the various conditions (BMT, CT, WLCG). Within each treatment condition, the assignment to the conjoint-group modality was not strictly random in that the groups were made homogeneous with respect to certain characteristics (age, children), applying randomization where possible. After inclusion in the study, 8 couples dropped out during therapy. These drop-outs were roughly evenly distributed among the conditions (BMT = 2, CT = 3, WLCG = 3), and were replaced. There were no significant differences between the therapy- and the drop-out couples regarding the socioeconomic and criterion variables.

Characteristics of Sample Eighty-five couples met the criteria and participated in the study (BMT = 17, BMTCG = 16, CTC = 16, CTCG = 19, WLCG = 17). The main marital/family character-

60

K. Hahlweg,

D. Revenstorf

and L. Schindler

istics are shown in Table 1. The mean age of the clients was 33.7 years. The couples had been married or had been living together for an average duration of 8 years. 90.3% of the couples were married and 74.5% had at least one child. All couples were middle-class. Regarding marital distress, the average duration of subjective distress was 3.8 years, 57.2% of the clients stated that they had a quarrel two or three times a week and in 64% of cases, the discord lasted at least for one day or night. Only 28.2% were satisfied with their sexual life, 45% had sexual intercourse less than twice a month. In terms of demographic and subjective characteristics the randomization process was successful. Statistical analysis revealed no significant difference between the groups on a variety of variables e.g. age, education, length of relationship, marital status, number of children, income, duration of distress, frequency of quarrelling and frequency of coitus. Table

1. Demographic

Groups, Range and Significance Test BMTC BMTCG CTC CTCG WLCG Range Significance Test d.F. (4, 84) Note.

characteristics

of the sample

and results

of tne significance

tests (Analysis

of Variance)

Variables N

Age

17 16 16 19 17

33.7 33.3 34.6 34.3 32.2 22.5 45.0 F= 0.7 p = 0.59

BMTC = Behavioral Marital Therapy CTC = Communication Training WLCG = waiting-list control group.

Length

of Marriage 7.5 8.2 7.4 9.1 7.7 1.0 17.0 F= 0.5 p = 0.71

conjoint; conjoint;

BMTCG CTCG

Length

of Distress 3.7 3.8 3.1 3.8 4.6 0.5 10.0 F = 0.5 p = 0.72

= Behavior Marital = Communication

Therapy Training

Children 1.2 1.7 1.3 1.4 1.4 O3.0 F= 0.6 p = 0.66 conjoint-group; conjoint-group;

Therapists Six male therapists including the authors treated the couples in the study. They were clinical psychologists with training in Behavior Therapy and had between two and five years of clinical experience. Every therapist carried out both treatment forms, with one therapist (L. S.) treating the majority of clients. In order to standardize therapist behavior written instructions for every session were used and frequent case-conferences were held.

Measures of Treatment Outcome Multiple outcome criteria were used to determine treatment effectiveness. The assessment battery is shown in Fig. 2.

Measures Partnership questionnaire (PFB) This 30-item questionnaire was developed for diagnosis and evaluation in conjoint marital therapy (Hahlweg, 1979). Three scales have been isolated by factor analysis, each having a high internal consistency (average Cronbach’s (Y= 0.85) and re-test reliability (average r = 0.75, 6 month interval, N = 50). The first scale (Quarreling) deals with aggressive or quarreling behavior. (“When we quarrel he/she keeps taunting me”). The second scale (Tenderness) includes items like: “He/she caresses me tenderly”. The third scale (Togetherness/Communication) includes items like: “We talk to each other for at least half an hour every day.“.The four answer categories are: never/very seldom, seldom, often, very often.

Treatment

Problem

list

of Marital

Distress

61

Pre

Post

FU I

x

X

X

X

X

X

rating

X

X

X

coding

X

X

X

X

X

IPL)

FU 2

PartnershIp questlonnalre

Happiness

(PFB)

Laboratory InteractIon (IMC/MIS)

Treatment

evaluation

questlonnalre

Rating

of therapists X

by client

FIG. 2. Overview

of measurements

at assessment

points.

The PFB has been satisfactorily cross-validated using several samples of normal and distressed couples (N= 750). Using the scale sum scores, the differential validity of the PFB was established by yielding highly significant differences (a) between non-distressed and distressed couples and(b) between treated and control couples. The scales also intercorrelate with relevant MICS categories (Hops, Wills, Patterson and Weiss, Note I), which infers that the PFB has a satisfactory construct validity. Problem list (PL) The problem list was used in the behavior analysis phase of the therapy. It consists of 17 possible problem areas of marriage, e.g., finances, household-management, leisure-time, sexuality, tenderness, and social activities. Each problem area is rated by each partner using the following categories: 0 = “No problem”; 1 = “Problems, but we can usually solve them”; 2 = “Problems we can’t find solutions for, and we often quarrel”; 3 = “Problems we can’t find solutions for, and we don’t discuss them anymore.” For the purpose of therapy evaluation categories 2 and 3 are summed yielding one conflict-score for each person. The retest reliability of this score is r = 0.66 (6 month interval, N = 50). The problem list was validated in an experiment with a group of 90 clients in marital therapy and a matched control group of 100 non-distressed partners (Hahlweg, Kraemer, Schindler and Revenstorf, 1980). General happiness rating This traditional rating scale was introduced by Terman (1938). In a pilot study (Hahlweg, 1979) this rating scale correlated highly (r = 0.88; without question number 1 of the MAT r = 0.81,N= 224) with the Marital Adjustment Scale (Locke and Wallace, 1959) and is therefore used as a global measure of success. The question is: “At this moment in time, how happy do you think your marriage/partnership is?” The six answer categories are: 5 = very happy, 4 = happy, 3 = somewhat happy, 2 = somewhat unhappy, 1 = unhappy, 0 = very unhappy.

62

K. Hahlweg,

D. Revenstorf

and L. Schindler

Marital interaction coding system (MICS) This is a frequently used behavioral coding system with 28 verbal and non-verbal codes (Hops et al., Note 1; for a review see Jacobson and Margolin, 1979, Chap. 4). In order to analyse the data, 21 MICS codes were collapsed into a positive and a negative category (positive: approve, agree, accept responsibility, compromise, humor, positive solution, attention, laugh, assent, positive physical; negative: complain, criticize, disagree, deny responsibility, excuse, interrupt, negative solution, put down, no response, not tracking, turn off). The behavior coded by the MICS consisted of couples interactions before and after therapy. For the first ten minutes, the couples had to solve up to four hypothetical marital problems from the “Inventory of Marital Conflict” (IMC) by Olson and Ryder (1970). Following this, they were asked to discuss a problem of their own for another ten minutes. These discussions were videotaped and later-on coded by trained raters who were blind to the experimental conditions. Interrater reliability was assessed by random checks and calculated by the formula agreement/agreement plus disagreement (point to point). The minimum criterion for acceptable reliability was 0.70. This figure was exceeded on virtually every check. The IMC and the MICS were successfully validated for the German cultural background (Hahlweg, Helmes, Steffen, Schindler, Revenstorf and Kunert, 1979). The questionnaires were given before and after therapy and at the follow-ups, 6 and 12 months after therapy. They were completed by both partners independently of each other. The laboratory interaction coding was conducted before and after therapy.

Measures of Treatment Comparability Treatment evaluation questionnaire A 9-item questionnaire was developed for the couple to assess the comparability acceptability of the different forms of treatment.

and

Rating of therapist by client A newly treatments. relating to consistency

developed questionnaire was used to assess comparability of therapists across The questionnaire is similar to an adjective-checklist and consists of the scales empathy, directivity, and personal style of therapist. The mean internal of the scales is 1y= 0.80.

PROCEDURE The flow chart of the two therapeutic procedures is shown in Fig. 3. For all treatment conditions the behavior analysis phase was identical. In Session 1, the aim of the initial interview was to gather enough information to decide whether the couple fulfilled the criteria for their inclusion in the study. If the couple was included and they agreed to participate they were assigned randomly to the experimental or control group. The waiting-list couples were videotaped (pretest) and all clients completed the questionnaires in the week following the first session. In Sessions 2 and 3 the partners were seen individually and their main relationship problems were analysed. Session 4 was again held conjointly. Here the therapist summarized the data collected in the previous sessions and gave a brief explanation of the rationale underlying their respective treatment program. The couple and the therapist then signed a therapy contract. Following this the couple was asked to engage in the described problem-solving discussion which was videotaped. They were also assigned a programmed textbook consisting of six chapters (CT)

Treatment

of Marital

Behaviour

Analysis

Initial

Theoretical

I L

Distress

+

BMT

Interview

Interview

Partner

A

Interview

Partner

B

basis

of

treatment;

contract

I Intervention

I

l-

Phase

Standard-Sltuatlons:

i

Standard-Situations:

5.

sess.

- Expression

of

6.

Sess.

- Emphatic

listening

7.

Sess.

8.

Sess.

feelings

- Positive

reciprocity

- Caring

days

speaker Interchange 1

63

of

skills

- Caring

speaker/listener

roles

days

speaker/listener

I

/

I

skills I

Own

Conflicts

Feedback-Session

FIG.

3. Flow

chart

of the therapeutic

procedures.

or seven chapters (BMT: Schindler, Hahlweg and Revenstorf, 1980). The chapters were to be read at home and served as preparation for the next treatment session.

Communication

Training (CT)

The CT-procedures were derived from Guerney’s “Conjugal Relationship Enhancement” (1977) and Berlin’s “Paare lernen Kommunikation” (1975). In the CT conditions the basic aim of the next four sessions was to teach the clients “speaker” and “listener” skills. During this didactic phase they role-played standardized problem situations in which each tried to make use of their new skills. Whenever one of the partners responded inappropriately the therapist interrupted, modelled better responses or used techniques like coaching, shaping, or prompting in order to produce the appropriate response. In Session 5 the speaker skills in the form of direct expression of feelings was introduced. Each partner practiced expressing his/her feelings in a direct, concrete and open way instead of accusing or blaming the other. In Session 6 the listener skills were trained. The clients had to practice listening actively to an open and direct statement from the speaker (looking at the other person, nodding, leaning forward, assuring), and giving feedback by paraphrasing the content of the speaker’s statements in their own words. The interchange of the speaker and listener roles during discussions of simple and more complex standard problem situations was practiced in Sessions 7 and 8.

64

K. Hahlweg,

D. Revenstorf

and L. Schindler

During Sessions 9-14 the clients then discussed their own problems using the newly learned skills and beginning with simple and easily solvable problems. A structured format was used for these conflict discussions (Schindler, Hahlweg and Revenstorf, in press).

Behavioral Marital

Therapy (BMT)

The BMT-condition consisted of four different components: (For the detailed therapist manual see Hahlweg, Schindler and Revenstorf, 1982). (a) Establishing positive reciprocity (Liberman, Wheeler, de Visser, Kuehnel and Kuehnel, 1980; Stuart, 1976) (b) Communication skills training as described earlier with emphasis on attitudes and thoughts about a problem as well as related feelings (c) Problem solving similar to Jacobson and Margolin’s approach (1979) (d) Crisis management (Meichenbaum, 1974; Novaco, 1975. The following scheme was used: In Session 5 the treatment component “Positive Reciprocity” was introduced to the clients using several standardized exercises. As a homework assignment the clients had to observe prositive behaviors of their partners (“Catch your spouse doing something nice”. Liberman et al., 1976). From Session 6 until the end of therapy the couples participated in “caring days” (Stuart, 1976). At the beginning of each session these homework assignments were reviewed. In Sessions 6 and 7 the speaker and listener skills as described earlier were outlined and practiced. From Session 8 onward the couple discussed their own problems using a structured discussion scheme. In Session 13 crisis management was introduced employing cognitive (self-instructional) techniques. Session 15 was identical for both treatment conditions. During this last session the therapist asked the couple for feedback regarding the therapy. Finally, the videotape posttest was administered and the couples were asked to complete the questionnaires during the following week. This concluded the standardized procedure for the conjoint therapy with one couple (duration of session about 50-60 minutes). The procedure for the conjoint-group modality was as follows: Sessions l-4 (behavior analysis) were carried out with each couple individually; Sessions 5-14 were done in groups of 3 to 4 couples with 2 therapists using the same treatment procedures as described earlier (duration of sessions about 2.5 hrs). In Session 1.5 each couple was seen individually for the videotape post-test. The videotape post-test for the couples in the waiting-list control group was administered 3 to 4 months after the initial interview. They were asked to complete the questionnaires during the following week and, if they requested it, received treatment (10 couples). Six months after the post-test an appointment was made with the treated couples for a follow-up interview. Twelve months after the post-test the questionnaires were mailed to the couples. Interviews were held only if the couples requested it. Couples did not receive treatment during the follow-up period.

RESULTS Statistical Data Analysis The statistical analysis was performed using SPSS (Nie, Hull, Jenkins, Steinbrenner and Bent, 1975). Couples were analysed as units using the average husband-wife’s score. The following statistics were used: (1) Pre-treatment comparison: Oneway, Duncan Test. (2) Post-treatment and FU 1,2 comparison: Anova, prescores as covariates. To determine possible group-differences contrasts (t-test) were computed using difference scores. Matched pair t-tests were used for within-group differences.

Treatment

of Marital

65

Distress

Treatment Acceptability In order to assess treatment acceptability clients were asked to evaluate the treatment f,u the end of therapy using a 9-item questionnaire. The main results are shown in Table 2. There were no significant differences between the BMT and CT format regarding the following questions. “Was the therapy a worthwhile experience for you?“, “Could you accept the theoretical concepts of the treatment?“, “Do you think that your relationship improved following the training?“, “Would you recommend the training to your best friends?“: More than 90% of all clients answered these questions affirmatively. The only significant differences found between the forms and modalities related to the duration treatment. Clients in the conjoint-group modality thought that the treatment was too short. (x2 (9) = 27.5, p = 0.001). In order to compare the different therapists, across the treatment formats, the clients’ perception of the therapist behavior was assessed using a questionnaire. The results are shown in Table 3. There were no significant differences regarding the following factors: empathy (therapist is seen as: feeling with the client, self-congruent, sympathetic, interested, genuine) and personal style (therapist is seen as: talkative, lively, self-disclosing). Clients in BMT perceived their therapist as more directive than CT clients (therapist is seen as: giving clear instructions, goals directed, providing feedback; t (186) = 2.0, p = 0.05). These results were expected due to the more structured format of the BMT conditions. The results on acceptability of treatment show that the formats seemed equally acceptable to the clients.

Table

2. Treatment

evaluation

ratings

(% agreement).

Chi -

Square

Test

Group Variable

BMT

CT

Significance

Test df

X2

Worthwhile Duration Acceptance Relationship Recommend

Table

experience of treatment of concept improved treatment

3. Clients

ratings

90.6 C = 78.2 CC = 46.9 95.3 96.9 93.7

of therapist

92.5 C = 66.6 cc = 33.4 90.9 95.5 94.0

behavior.

Means

(M) and standard per factor

P

3.0 27.5

2 9

0.22 0.001

0.1 3.7 0.5

2 2 2

0.95 0.16 0.83

deviations

(SD), and significance

test (t-Test)

Variables Group Test BMT CT r-Test (dj’=

and Significance

186)

Empathy M 72.4 70.9 / = 1.0 p = 0.34

SD 11.1 10.8

PrdPostcomparisons

Directivity M 48.3 46.4 f = 2.0 p <0.05

SD 6.0 7.1

Personal M

Style SD

24.2 23.7 t =0.6 p = 0.56

6.2 6.5

on Criterion Variables

Oneway-analysis of the prescores revealed no significant differences between the five groups at the beginning of therapy on any of the variables. The means, standard deviations, and the results of the significance tests for the criterion variables before and after therapy for the experimental groups and the control group are shown in Table 4.

66

K. Hahlweg, Table

4. Means

(M) and standard

D. Revenstorf

deviations

(SD)

and L. Schindler on criterion

variables

at pretest

and post-test

Groups

Variables

Tenderness Communication

General Happiness MICS Positive Behavior Negative Behavior Note.

CG Pre Post

Pre

CT C Post

CC Pre Post

WLCG Pre Post

Pre

11.9 8.8 5.4 6.0 II.1 13.1 4.3 6.1 13.7 15.9 5.1 4.8

II.2 8.2 5.0 4.5 13.1 14.6 4.1 5.1 14.1 16.5 3.9 4.2

14.1 10.9 3.8 4.1 II.4 13.7 4.9 4.5 14.1 16.2 2.8 3.2

11.7 II.2 3.8 3.8 II.3 12.3 5.0 5.4 14.5 14.9 4.0 4.1

II.2 3.9 10.4 4.6 13.4 3.4

10.8 3.7 9.8 4.3 12.6 3.3

F= p = F = p = F = p =

Pre

PFB Quarrelling

PL Conflict

BMT C Post

Score

M SD M SD M SD

Significance

Tests Post

I.2 0.33 0.7 0.59 0.2 0.92

F= p = F= p = F= p =

2.9 0.03 2.2 0.08 4.1 0.005

M SD

6.9 1.9

3.1 2.5

7.1 2.9

4.1 3.0

1.6 2.8

4.4 2.9

6.5 2.6

4.7 3.1

7.8 1.9

7.2 I.8

F= 0.7 p = 0.60

F = 5.0 p = 0.001

M SD

I.7 0.7

3.3 0.8

2.3 0.9

3.3 0.9

I.8 1.0

2.8 I.0

2.3 0.9

2.8 1.0

2.3 1.0

2.3 0.9

F = 2.0 p = 0.11

F= 7.3 p = 0.000

M SD M SD

3.6 I.4 4.1 2.0

4.7 I.9 2.1 1.4

3.8 I.0 3.6 1.0

4.6 1.3 2.4 I.5

3.7 0.8 3.6 I.5

3.7 I.3 2.6 2.0

3.3 I.1 3.3 1.2

4.0 I.3 2.2 I.4

3.5 1.9 3.1 1.6

3.7 I.0 3.6 I.3

F = p = F= p =

F= p = F= p =

MICS behavior = rate per minute. Degrees to technical failures of video equipment.

of freedom

for self-report

measures

0.4 0.83 0.7 0.60

= 4.79;

MICS

I.6 0. I9 2.7 0.03

= 4,71, due

For the PFB Quarreling scale analysis of covariance revealed a significant overall difference between the groups F (4, 79) = 2.9, p <0.03. After therapy couples in BMT and CTC reduced quarreling behaviors compared to the beginning of therapy while couples in CTCG and WLCG remained unchanged. For the PFB Tenderness scale, analysis of covariance approached significance F (4, 79) = 2.2, p <0.8. After therapy couples in BMT and CTC reported more tenderness behavior compared to the beginning of therapy whereas couples in CTCG and WLCG remained unchanged. For the PFB Communication scale, statistical analysis was significant F (4, 79) = 4.1, p <0.005. After therapy couples in BMT and CTC reported a significant increase in feelings of togetherness and communication whereas CTCG and WLCG couples remained unchanged. For the Conji’ict Score of the PL, analysis of covariance revealed a highly significant difference between the groups F (4, 79) = 5.0, p
Treatment

of Marital

Distress

61

of Change

Stability

In the period between the end of therapy and FU 1,lO couples separated; only one couple separated from FU 1 to FU 2. The separated couples were evenly distributed across the formats but more couples separated in the conjoint modality (9) compared to the conjointgroup modality (2).Some 16.2%, of all treated couples separated within one year following the treatment. In order to avoid different N’s, follow-up analyses excluded the separated couples. Subsequent statistical comparison of modalities within each treatment format revealed no significant differences (Revenstorf, Schindler and Hahlweg, in press; Schindler, Hahlweg and Revenstorf, in press). Therefore, follow-up analyses were performed combining conjoint and conjoint-group modality within each treatment format with 28 couples in BMT and 29 couples in CT. In Tables 5 and 6 the means, standard deviations, and the results of the significance tests for the self-report measures at the four assessment times are shown. Table

5. Means

OM) and standard

deviations

(SD) on criterion variables non-separated couples

at pre-test,

post-test,

FUl

BMT Variables PFB

-

Quarrelling

M SD M SD M SD M SD M SD

Tenderness Communication PL

-

Conflict

General

Table

Score

Happiness

6. Significance

tests (Oneway,

Pre

Post

FUl

FU2

Pre

Post

FUl

FU2

11.5

8.2 5.1 14.7 4.7

8.6 4.4 13.8 6.1

10.4

11.8

11.6

14.3

16.8

4.6 7.0 2.5 2.2 0.9

4.3 3.4 2.1 3.4 0.7

15.8 5.1

8.6 3.9 13.7 5.5 16.4 4.6 3.2 2.4 3.1 0.9

12.3

5.3 12.9 4.2

3.8 11.6 4.8 14.8 3.5 6.7 2.4 2.2 0.8

3.8 13.3 4.9 15.9 3.9 4.1 2.9 3.0 0.8

4.4 12.3 5.2 15.2 3.9 4.1 3.1 2.7

4.0 11.2 5.7 14.8 3.7 4.5 2.9 2.7 0.8

Anova,

r-Test)

Pre

4.0 3.1 3.1

1.0

regarding variables

PFB Quarrelling Tenderness Communication PL ’ Conflict General

Note.

Score Happiness

Pre, Post,

FUl

FU2

BMT

F = 0.4

F =

F = 10.0

F=

p =

0.69

p < 0.01

p<

p<

F=

1.6

F=

F=

0.003 0.2

p =

0.21

p<

p=

0.66

p = 0.40

F=

1.1

F = 2.4

p =

0.31

p =

F = 0.7

F=

p =

0.50

p<

F=

1.4

4.9 0.01 7.8 0.001

on the criterion

r-Test

FUI

4.6

1.1

and 2 comparison

Anova Post

F=

7.7

CT

I/3p

= o.cMIo

1/4p

= 0.002

0.13

1/3p 1/4p

= 0.003 = 0.08

0.008 0.7

F = 10.1

F=

0.2

F = 5.0

1/3p

= 0.000

1/3p

= 0.000

p = 0.25

p < 0.001

p =

0.65

p =

0.05

I/4p

= 0.000

F= 0.1 p = 0.91

F=

F=

2.2

F=

2.3

I/4p = 0.000 I/3p = o.coo 1/4p = 0.001

p<

17.4

0.001

Only non-separated couples are included. Anova FU l/2 = 1, 54; for t-Test = 56.

for

CT

Oneway Variables

and FU2

p = 0.15 Degrees

p = 0.14 of freedom

for Oneway

and Anova

1/3p

= 0.01

I/4p

= 0.01

post = 2,71;

for

For the PFB Quarreling scale, analysis of covariance was significant on both follow-ups (FU 1: F(1, 54)~ 10.0,~ <0.003; FU 2: F (1, 54)=7.7,p cO.008. BMT couples reported a significant and stable decrease of quarreling behavior compared to CT couples who returned to their pre-treatment level (Fig. 4). No significant differences were found between BMT and CT on the PFB Tenderness scale. Couples in both formats relapsed to theirpretest level (Fig. 5). For the PFB Communication scale, analysis of covariance revealed no difference between the two formats. Couples in BMT remained stable while CT couples relapsed to pretreatment level (Fig. 6).

K. Hahlweg,

68

PFB-SCALE:

D. Revenstorf

and L. Schindler

QUARRELING

20 01 n BMT 0 CT . WLCG

l *

0.0

1

N. S. I PRE N. S.

PFB-SCALE:

I POST l

*

I FU-1 l

.

p <

.Ol

p >

05

8 FU-2 11

TENDERNESS

20 0 . BMT o CT . WLCG 1

3

lO.O-

\

l

,,,I

, PRE NS

FIGS. 4-g.

Mean

,

,

WST l

*

FU-1 N

S.

,

*

NS

: P < .ot P’

.05

FU-2 N

S.

scores on criterion variables for each group and assessment time. Stars indicate statistical significance between the groups for non-separated couples.

level of overal

Treatment

PFB -SCALE:

of Marital

Distress

69

COMMUNICATION . EMT o CT . WLCG

I

1

PRE NS

POST * .I

I

1

FU-1

Fu-2

NS

NS

P L: CONFLICT- SCORE 10 0

1

. BMT 3 CT . WLCG

*** : p < * : p < N S : p ' 0 0

I PRE N.S.

I WST l **

1 FU-1 N

S.

I FU-2 l

.OOl .05 .05

K. Hahlweg,

D. Revenstorf

and L. Schindler

GENERAL HAPPINESS *EMT OCT AWLa

For the Conflict Score of the PL, analysis of covariance was not significant at FU 1: F (1, 54) = 0.2, p 3.0), the average CT couple scored within the unhappy range (A4 G2.9) (Fig. 8).

DISCUSSION When considering the short-term effectiveness of the various treatments the following conclusions can be drawn: CTC and BMT (irrespective of modality) are superior to the WLCG in 6 out of 7 comparisons while CTCG is superior in only 1 out of 7 comparisons. Couples in BMTC are superior to couples in BMTCG and CTC in reducing their amount of problem areas and increasing their general happiness. Considering BMT and CTC alone, the results are consistent with the literature showing that these approaches are superior to either a no-treatment or a non-specific control group (Jacobson, 1978a). The most surprising result is the failure of CTCG (which is the normally applied modality using a CT format) when compared to the waiting-list control group. There are some possible explanations for this finding. In the BMT condition the focus of intervention is twofold, increasing the positive aspects of a given relationship and decreasing the negative aspects; whereas in the CT condition the intervention addresses the problems in the relationship and therefore focuses, in the main, on the negative aspects of the relationship. This may lower the treatment expectation and motivation of the CT couples. Secondly, in the CT formats, problem-solving is not explicitly trained. Couples did experience that they could indeed communicate better about their problems. Specifically in the group modality most couples experienced small or no change in their problematic behaviors afterwards because they lacked appropriate models. This reduced the actual use of the newly learned skills in everyday life. Thirdly, the treatment in a conjoint group format

Treatment

of Marital

Distress

71

is less intensive than in a conjoint format due to the attempts to increase group cohesion during the sessions. This also reduces the opportunity to practise the new skills. In sum, these conditions may explain the failure of CTCG which on the basis of these results cannot be recommended as a treatment for moderately distressed couples. When considering the longterm effectiveness, BMT seems to be moderately superior to CT. Within analysis revealed that BMT couples remained stable compared to pre-treatment scores in 4 of 5 variables, whereas CT couples remained stable in only 2 of 5 variables. Couples in BMT were significantly superior to CT couples in 2 out of 5 variables. They reported less conflict areas and less aversive behavior in conflict at FU 2. These results are in contrast to those of O’Leary and Turkewitz (1978) and Wieman (Note 2). The major difference between their BMT format and the present one is in the explicit focus on increasing positive reciprocity between partners which may stabilize alternative problemsolving behaviors acquired during therapy. However, when comparing BMT with other approaches BMT seems to be somewhat superior in the long run (Boelens et al., 1980; Crowe, 1978; Liberman et al., 1976). This is consistent with the present findings. Regarding the separation rates after therapy there are pronounced European/American differences when considering the studies which employed a longer follow-up. Jacobson (1977, 1978b), Liberman et a/, (1976), and O’Leary and Turkewitz (1978) reported no definite separations during follow-up while Boelens et al. (1980) reported two (= 12.5% of the treated sample) and Crowe reported seven separations (= 16.7% of the total sample). These two rates are comparable with ours (11 = 16.2% of treated couples). There is very little known about the base-rate of separations after regular marital counseling because of the absence of systematic longitudinal follow-up. The one exception is the study by Cookerly (1980) who did a 5 year follow-up of 326 clients treated by various forms of marital therapy in the USA. Those who were treated primarily by conjoint therapy had a separation rate of 43.6% after 5 years, showing the largest number of separations in the first year [14% and decreasing to 9.2%, 6.3%, 9% and 5.1% respectively]. Regarding the first year rate, the results of the European studies are comparable. However, it is difficult to assess whether a separation constitutes a treatment failure or success. One of the mutually agreed aims of our therapy (for the participants) is that the treatment should enable the couple to bring about a decision regarding their staying together or their separation by the end of therapy. If they decide to separate this process is expected to be less harmful and humilating to each partner compared with couples who separate without therapy. Unfortunately there are no valid measures to assessa “successful separation”, so we are left with our clinical impression that about 50% of our separations could be regarded as successful. Finally one should mention the clinical significance of our results. When looking at General Happiness at FU 2, BMT couples scored on the average within the “happy” range while the average CT couple scored within the “unhappy” range. Considering the other criterion variables, there is still a substantial difference between the treated sample and the non-distressed couples. Comparisons of the means with normative data (PFB: Hahlweg et al., 1982; PL: Hahlweg et al., 1980) indicate that even the BMT couples score on average 1 standard deviation below the respective non-distressed means at post-test, FU 1 and 2, showing the relative value of statistical significance. Therefore one future aim of research should be the thorough investigation of those couples who do not respond to a BMT approach in order to develop a more effective means of treatment. Acknowledgement - This Grant No. Re 402/l-5.

report

was supported

by the Deutsche

Forschungsgemeinschaft

(DFG).

APPENDIX Communicarion

Skiffs

Training

This standardized therapy program was developed on the basis of a literature review and of our own therapeutic experiences. The procedures were mainly derived from Guerney’s “Conjugal relationship enhancement” (1977) and Berlin’s “Paare lernen Kommunikation” (1975) a German version of the HDI program. The program consisted of two phases: basic skills training (Sessions 5-8) and problem solution (Sessions 9-14). In addition the couples were

K. Hahlweg,

72

D. Revenstorf

and L. Schindler

assigned a programmed text-book consisting of six chapters, which is a re-written version of the book “Couples learn communication” (Human Development Institute; Berlin, 1975). The basic aim of the Sessions 5-8 was to enable the clients to learn and practice the following speaker and listener skills:

Speaker

skills

(1) Use I-messages (express your own feelings about the topic). (2) Describe specific situations (speak of specific situations in order to avoid generalizations like “always” “never”). (3) Describe specific behaviors (speak of specific behaviors in specific situations in order to avoid labels “lazy” or “cold”). (4) Stick to the “Here and Now” (discuss one problem at a time in order to avoid side-tracking). In general, these skills should enhance the self-disclosure of the speaker.

Listener

or like

skills

(1) Listen actively (indicate by your non-verbal behavior that you are listening to your partner by body posture, facial expression, and assenting). (2) Paraphrase (summarize your partner’s remarks and check their accuracy). (3) Ask open questions (when you do not understand your partner’s feelings/thoughts). (4) Give positive feedback (for appropriate responses by your partner). (5) Give feedback of your own feelings (when hurt by a statement of your partner, respond with an I-message). During the didactic phase the couple role-played standardized problem situations trying to make use of these new skills and training the interchange of the speaker and listener roles while discussing simple and more complex conflicts. In the problem solution phase of the program the clients then discussed their own problems, beginning with rather simple and easily solvable problems. The following scheme of conflict discussion was used: In Step 1 each partner had to express his feelings about the problem in the most direct and open way (conveying of feelings) while the other partner provided feedback; in Step 2 both partners had to describe their wishes and needs regarding the problem; in Step13 the couple usedia brainstorming procedure to generate possible solutions to the problem; and in Step 4 the couple tried to reach an agreement. Specific problem-solving and contract management as used in Behavior Marital Therapy were not included in the treatment.

Behavioral This

treatment

(1) Establishing

program

positive

consisted

of four different

Marital

Therapy

components

(see Hahlweg,

Schindler

and Revenstorf,

1982):

reciprocity

To enhance partner and self-observation with regard to positive verbal and non-verbal behaviors a homework assignment developed by Liberman et al. (1976) was used during the first week of treatment: “Catch your spouse week onward couples were asked doing/saying something nice and let him/her know about it.” From the following to perform “Caring days” (Stuart, 1976). In this procedure each partner had to choose one day of the week on which he was asked to emit caring behaviors indenendently of the actions of the spouse. Each partner had to record the planned and received caring behaviors. At the beginning of each treatment session the course of the “Caring days” was reviewed.

(2) Communication

skills

training

In this component the speaker and listener skills as described who employ the communication skills in turn should avoid mutual understanding, and generate specific solutions to disclosure of feelings, attitudes, and thoughts either about a point of discussion, and accepting (not necessarily agreeing

(3) Problem

solving

beforehand were trained (Sessions 6and 7). Partners blaming, criticizing and side-tracking, increase their their problems. The core skills are reciprocal selfspecific problem in the relationship or about a general to) the speaker’s utterances.

training

To help the couple solving their own problems a structured discussion scheme was developed: In Step 1 both partners conveyed their views of the conflict, disclosing their feelings, thoughts, and attitudes toward the problem, and giving mutual feedback. In Step 2 each partner described his needs and wishes regarding the problem. In Step 3 they had to generate specific solutions for the problem in a brainstorming fashion. In Step 4 a balanced agreement had to be negotiated and an informal “good-faith” contract was written out.

Treatment (4) Cri.ris

of Marital

Distress

13

management

This treatment component was introduced at the end of therapy in Session I1 or 12 as it was intended to enhance generalization through facilitating the use of the previously trained problem-solving skills, particularly in crucial situations. By “crisis” a situation is meant in which aversive exchanges tend to escalate. If one follows a progressive escalation process, one can identify four stages. For each of these stages an inner dialogue (Meichenbaum, 1974) is trained which can help to avoid the increase of an aversive exchange and support direct communication. Thefirsr stage represents the period before one spouse points out a specific behavior pattern in the other which is particularly disliked. In such a case the following questions should preceed any overt behavior: (I) Do I think this behavior is really important enough to discuss or change? (2) Is this reaction only occasional. and am I usually content with this issue? (3) Have I contributed to the behavior? In case the client decides that it is important to discuss the event, then the following should be considered in the momentary situation: Is it appropriate to engage immediately in a problem discussion? Sfage fi+‘o becomes relevant when the spouse decides that the conflict issue should be addressed now and that the situation is appropriate. At this point the communicationskills trained in the treatment should becomeoperational. This means to omit blammg and to express feelings directly. Although the other spouse may not at once react in a constructive manner. it should be remembered that responsibility for successful problem-solving discussions resides primarily with the dissatisfied partner. Stage three represents coping with an imminent quarrel. In spite ofall efforts to the contrary, a quarrel may ensue. In this case the client should interrupt the conversation in order to avoid an imminent escalation. She/he should directly express her/his fears, ask for a time-lapse, and suggest the resumption of the discussion later. If everything has gone wrong in that the prevention of escalation has failed, and communication has broken down (Stagefour). then each spouse must feel responsible for again adopting positive interaction. Each should consider whether they are prepared to tolerate a day or two of tension until the other gives in, or take the first step and have, for instance. an enjoyable weekend together. This “weighing up” or appraisal is the essential characteristic of the cognitive training at all four stages. The clients are coached in anticipation of outcone and decision-making according to their individual priorities. The inner dialogues along the described rationale are trained by means of their typical conflict situations.

Reference I.

2.

notes

Hops, H.. Wills, T. A.. Patterson. G. R. and Weiss, R. L. Marital interaction coding system. Unpublished manuscript, University of Oregon and Oregon Research Institute, 1972. See NAPS Document 02077 for 29 pages of supplementary material. Order from ASIS/NAPS, c/o Microfiche Publications, 440 Park Avenue South. New York, N.Y. 10016. Remit in advance $1.50 for microfiche, $5.00 for photocopies. Make cheques payable to Microfiche Publications. Wieman, R. J. BehavioralandRogerian group marital therapy: n comparison. Paper presented at the convention of the Association for Advancement of Behavior Therapy, New York, 1976.

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and L. Schindler

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