This article was downloaded by: [University of South Florida] On: 09 October 2014, At: 13:44 Publisher: Routledge Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK
Journal of Sex & Marital Therapy Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/usmt20
A randomized clinical trial of cognitive marital therapy a
b
b
Edward M. Waring , Claudia Carver , Carol A. Stalker , Richard b
Fry & Betsy Schaefer a
b
Queens University
b
Department of Psychiatry , University Hospital Published online: 14 Jan 2008.
To cite this article: Edward M. Waring , Claudia Carver , Carol A. Stalker , Richard Fry & Betsy Schaefer (1990) A randomized clinical trial of cognitive marital therapy, Journal of Sex & Marital Therapy, 16:3, 165-180, DOI: 10.1080/00926239008405263 To link to this article: http://dx.doi.org/10.1080/00926239008405263
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/termsand-conditions
A Randomized Clinical Trial of Cognitive Marital Therapy
Downloaded by [University of South Florida] at 13:44 09 October 2014
EDWARD M . WARING, CLAUDIA CARVER, CAROL A. STALKER, RICHARD FRY, and BETSY SCHAEFER
Thirty-three couples with severe marital discord referred to a psychiatric outpatient department were randomly assigned to Cognitive Marital Therapy or a control group. Cognitive Marital Therapy is a brief, structured couple therapy, which involves spouses in reciprocal sevdisclosure of personal constructs. The control group received the same number of sessions of self-disclosure from a programmed marital enhancement text. Personal distress, marital adjustment, marital quality, and aspects of self-disclosure were measured before and afer treatment. Symptoms of depression as well as somatic and compulsive complaints showed significant improvement in both groups. The wives exhibited a trend suggesting that they were making more self- disclosures to their spouses afier counseling. No discernable differences in outcome were found between the marital therapy group and the control group. Marital intimacy and marital satisfaction did not improve significantly over the course of 10 therapy sessions. This study suggests that the role of seydisclosure in marital therapy needs further clarification. Jourard defined self-disclosure as the process of verbally revealing one’s feelings, thoughts, and needs to another person.’ Spouses who report more self-disclosure in their marriage tend to report greater marital satisfaction.2 Couples with marital discord report reduced amounts of self-disclosures, which are not affectively c ~ n g r u e n t . ” One ~ might assume that a technique that increases the amount of self-disclosures between spouses, insures the reciprocity of these disclosures, and attempts to facilitate self-disclosures that are affectively congruent might be effective in reducing marital discord. Cognitive Marital Therapy (CMT) is Edward M. Waring, MD, is Chairman of Psychiatry and Professor, Queens University. Claudia Carver, MSW, CSW, and Carol A. Stalker, MSW, CSW. are both Social Workers, Department of Psychiatry, University Hospital. Richard Fry, BA, and Betsy Schaefer, BA, are both Research Assistants, Department of Psychiatry, University Hospital. Address reprint requests to: Dr. E. M. Waring, Hotel Dieu, 166 Brock Street, Kingston, Ontario, N7L 5G2, Canada.
Journal of Sex & Marital Therapy, Vol. 16, No. 3, Fall 1990 0 BrunnedMazel, Inc. 165
Downloaded by [University of South Florida] at 13:44 09 October 2014
a standardized, structured, brief marital therapy designed to enhance marital intimacy through facilitating cognitive self-dis~losure.(~.~ Cognitive Marital Therapy was developed from Kelly’s theory of personal constructs.8 Neimeyer!’ l o has written about a personal construct approach to marital counseling and suggests that spouses choose those alternatives that appear to offer the greatest opportunity to extend and define personal understandings of experience. Kellys observed, “A man will choose to marry if that appears to provide him with the opportunity to enlarge or secure his anticipatory system” (p. 523). Waring“ suggests this “anticipatory system” develops largely from the observation and experience with one’s parents’ level of marital intimacy. SegravesI2 has developed Kelly’s model for the treatment of marital discord suggesting: 1 ) faulty cognitive schemata of members of the opposite sex are of primary importance in the genesis and maintenance of marital discord; 2) spouses tend to behave toward one another in such a way as to invite behaviors that are congruent with personal constructs; and 3) maladaptive interactional patterns maintain individual psychopathology in spouses. Controlled outcome trials o f marital therapy in psychiatric clinical settings involving patients o r couples have been rare. Friedman’s13study of the combination of marital therapy and antidepressants in depressed outpatients and Crowe’s’Jresearch with neurotic outpatients are the only two to the best of our knowledge. Two controlled outcome trials of Cognitive Marital Therapy in combination with antidepressants in hospitalized women with major affective disorder and outpatient women Lvith dysthyrnia have been reported.’”‘“T h e present study evaluates the effectiveness of Cognitive Marital Therapy (CMT) in couples with severe marital discord attending a psychiatric outpatient clinic.
Hypotheses Specific hypotheses concerning the effects of Cognitive Marital Therapy (CMT) on the marital relationship and on presenting symptoms are as follows: 1 ) Compared to a control treatment group, CMT will result in greater improvement of marital functioning after 10 sessions. This would be evidenced by reduced scores on the Marital Satisfaction Inventory (MSI) scales originally defined as problematic and, thus, a more “normal” MSI profile at the posttherapy assessment. 2) Compared to the control group, CMT will result in improved marital intimacy. Specifically, subscales of the Waring Intimacy Questionnaire (WQ) and WIQ Total Intimacy scores should exhibit greater improvement after 10 weeks. 3) Compared to the control group, CMT will result in increased selfdisclosure after a 10-week period. Greater increases should be found o n the Self-Disclosure Questionnaire. After 10 weeks, the CMT group can be expected to demonstrate larger increases in scores on the SelfDisclosure inventory than will the control group.
A Randomized Clinical Trial of Cognitive Marilal Therapy
167
4) CMT will show an improvement over the control group in symptom reduction over 10 weeks. General Health Questionnaire (GHQ) and Symptom Check List (SCL-90) scores will show more decline in the active treatment group.
METHOD
Downloaded by [University of South Florida] at 13:44 09 October 2014
T h e research design stipulated the following inclusion criteria for each couple:
1 ) T h e presenting problem was marital discord, consisting of frequent arguments, or conflicts over differences of opinion. 2) Spouses were to have been in a stable marriage, either living together, or recently separated from a marriage of at least 5 years. 3) One o r both spouses may have had a score greater than 4 on the General Health Questionnaire, but no evidence of major psychiatric disorder. 4) A t least one of the spouses’ Total Intimacy scores on the W I Q would be below 22, with two of three scores on Affection, Conflict Resolution, and Compatibility being the lowest. Couples satisfying the inclusion and exclusion criteria were randomly assigned either to 10 sessions of CMT o r to 10 sessions of a control treatment, which will be described. Thirty-three couples were included in the study, and all of them were expected to read one chapter per week from the marital education manual, Time for a Better M a r r z ~ g e . ’ ~ Treatments
Cognitive Marital Therapy. CMT is a structured, time-limited intervention. It can be summarized and specified by the instructions to therapists to comply with the following nine things to do: 1) Explain the sessions and treatment contract to couples. 2) Initiate each session with the question “What were you thinking while your spouse was talking?” or the last question from the previous session. 3) Facilitate self-disclosure of personal constructs. Spouses are asked to disclose, individually to the therapist, their theories as to why they are not close as a couple. Each is asked to speak in turn, comment upon each other’s disclosures, and to give additional information when necessary. 4) Clarify any ambiguous disclosures made by either spouse during a session. 5 ) Redirect the attention of spouses to the discussion at hand, when warranted, or to personal constructs they have previously disclosed, when appropriate.
168
J o u n i d of Spx &f Marital Therapy, V d 1 6 , N o . 3 , Fall 1990
6) Ask nondirective questions to encourage the disclosure of personal constructs. 7) Encourage the exploration of the parents’ marriage. 8) Extend this exploration to the marriages of grandparents, friends, and other couples. 9) I n later sessions, present the therapist’s theories as to why the couple a r e not close, as material for discussion.
Downloaded by [University of South Florida] at 13:44 09 October 2014
Also, the CMT protocol includes the following five things not to do: 1 ) Do not allow outbursts of emotion to interfere with the discussion process. Instead, coach and model good listening skills. 2) Do not allow assumptions tantamount to “mind reading” between spouses, but redirect such material to its conscious, cognitive components. 3 ) Do riot confront or identify nonverbal behaviors of spouses, unless they disrupt the treatment contract. 3 ) Do riot allow the spouses to interrupt each other’s disclosures during sessions. 5) Do not interpret resistances. Terminate sessions if couples will n o longer mutually self-disclose or attend sessions. Cognitive Marital Therapy is presented in 10 hour-long, weekly session?. A therapist manual is available for the training of therapists in Cognitive Marital Therapy to ensure a structured, standardized approach. Audiotapes of sessions were supervised to ensure standardization of therapy.
Control Therapy. Waiting-list control subjects rarely improve without In the experience of Fiske et al.‘O a n d the authors, waiting-list subjects pose significant threats to research designs in terms of dropouts, couples separating, and the seeking of help elsewhere. Instead of a waiting-list, w e used a control therapy group in which a marital, interpersonal-skills training manual, Timefor a Better Marrzage, was given to the couples. They were expected to read one chapter per week a n d self-disclose their thoughts about the chapters with a research assistant in 10 hour-long, weekly sessions. Control marital counseling was a n ad hoc, couple-directed intervention. T h e material in the book covers stand a r d communication skills, mutual encouragement, establishment of objectives, a n d behaviors to practice. T h e research assistant modeled listening skills, a n d directed couples to focus o n passages that referred to problems they experienced, and to recognize those areas in which they were free of conflict. When couples claimed that the material was not applicable to them o r digressed into domestic conflicts, the research assistant showed them where concepts in the book were more cogent than they had realized. Couples understood that they could enter C M T after 10 sessions of control marital counseling. T h e major differences between CMT and control counseling were that CMT therapists were trained in marital counseling, while the research
A Randomized Clinical Trial of Cognitive Marital Therapy
169
assistants had no formal training in the area; CMT has an inherent structure to its sessions, but control counseling was client-centered and structured only by the material in the book; and CMT requires spouses to explore their personal constructs regarding their attitudes and expectations, while control therapy was oriented toward encouraging couples to have faith in their own ability to resolve their problems. However, all couples read the same text and were involved in sessions promoting selfdisclosure.
Downloaded by [University of South Florida] at 13:44 09 October 2014
Data Collection Procedure Immediately after the initial assessment interview, couples completed a number of self-report inventories described below and a demographic information questionnaire. They then began the therapy sessions: 10 weeks of CMT or the control treatment. After 10 weeks, the measures were repeated with the exception of the demographic form and the personality questionnaire (to be described). In addition to these assessments, audiotapes were made of some sessions to monitor patient and therapist compliance with the study protocol. Differential dropout rates between the CMT and control groups were examined. At the end of 10 weeks, the couples in the control group were offered Cognitive Marital Therapy. Statistical Analyses T h e hypotheses described above were tested using repeated measures analyses of variance, with treatment condition as a between-groups factor. Each of the psychological constructs (i.e., marital functioning, marital intimacy, self-disclosure, and symptomatology) were measured by several scales or subscales. Each of these were analyzed separately, but interpreted within their overall constructs, and with respect to results that may be d u e to chance. Pretherapy levels of the constructs measured were tested between treatment groups to assess the effectiveness of the random assignment process, as suggested by Bancroft, Dickerson, Fairburn, Gray, Greenwood, Stevenson and Warner.*’ Groups of subscales identified as the most likely to have an effect on therapy outcome were entered into multivariate analyses of variance, with therapy type used as the treatment factor. Dropout rates were examined as an outcome d u e to therapy type via a Chi-squared analysis of cross-tabulated categorizations. T h e effects of pretherapy levels on outcome measures of personality traits and demographic characteristics on dropout status were analyzed with multivariate analyses of variance in subsets of related measures. Measures Measures were chosen to assess three theoretical constructs: the marital relationship, the presenting complaint or symptomatology, and person-
ality and demographic characteristics that may moderate responses to psychotherapy. Symptoms of psychiatric illness were monitored, since they have been shown to be associated with marital
Downloaded by [University of South Florida] at 13:44 09 October 2014
Marital Relalionships Iwtrzi?nent.s
Ma?-ital Satisfaction Inventory. T h e MSI is a self-report measure that identifies the nature and extent of marital distress along several dimensions.')>I t consists of 280 true-or-false items on 1 1 scales. N o total score is produced, but one of the scales offers a measure of overall marital discontent . T h e 1 1 scales are as follows: Conventionalization (CNV), the tendency to distort the appraisal of the marriage in a socially desirable direction; Global Distress (GDS), overall dissatisfaction, along the dimensions of general unhappiness with the marriage, and uncertain commitment to the marriage; Affective Communication (AFC), dissatisfaction with the amount of affection and understanding expressed by the spouse, referring t o inadequate affection anc! caring, lack of ern pathy a n d understanding, and failure of the spouse to self-disclose; Problem-Solving Comniunication (PSC), the couple's general ineffectiveness in resolving differences; Time Together (TTO), reflecting lack of common interests a n d dissatisfaction with the quality and quantity of leisure time together; Disagreement About Finances ( F I N ) , discord regarding the management of family finances; Sexual Dissatisfaction (SEX), dissatisfaction with the frequency and quality of sexual activities; Role Orientation (ROR), reflecting adoption of a traditional versus nontraditional orientation toward marital and parental sex roles; Family History of Distress (FAM), reflecting a n unhappy childhood and disharmony in the marriages of respondent's parents 'and extended family; Dissatisfaction With Children (DSC), dissatisfaction or disappointment with children, reflecting parent-child rather than between-spouse relationships; and finally, Conflict Over Childrearing (CCR), the extent of conflict between the spouses regarding childrearing practices. Except for C N V a n d ROR, all scales are scored in the direction of discontent so high scores indicate high levels of dissatisfaction within t h e specific area. T h e number of items differs for each scale a n d maximum raw scores can range from 15 on FAM t o 43 o n GDS.
Waring Inlzmacy Questionnuire. The WIQ is a 90-item true-or-false questionnaire specifically developed to measure the quality a n d quantity of marital intimacy.'6 T h e W I Q was developed from the theory that t h e quality of intimacy between the spouses is the major determinant of marital adjustment, and the quantity of intimacy is negatively correlated with the presence and severity of nonpsychotic emotional illness in one or both of the spouses. T h e W I Q measures eight facets of marital intimacy: Conflict Resolution (CR), the ease with which differences of opinion are resolved; Affection (AFF), the degree to which feelings of emotional closeness a r e expressed
Downloaded by [University of South Florida] at 13:44 09 October 2014
A Rundomized Clinical Trial of Co
Journal of Sex & Marital Therapy Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/usmt20
A randomized clinical trial of cognitive marital therapy a
b
b
Edward M. Waring , Claudia Carver , Carol A. Stalker , Richard b
Fry & Betsy Schaefer a
b
Queens University
b
Department of Psychiatry , University Hospital Published online: 14 Jan 2008.
To cite this article: Edward M. Waring , Claudia Carver , Carol A. Stalker , Richard Fry & Betsy Schaefer (1990) A randomized clinical trial of cognitive marital therapy, Journal of Sex & Marital Therapy, 16:3, 165-180, DOI: 10.1080/00926239008405263 To link to this article: http://dx.doi.org/10.1080/00926239008405263
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/termsand-conditions
A Randomized Clinical Trial of Cognitive Marital Therapy
Downloaded by [University of South Florida] at 13:44 09 October 2014
EDWARD M . WARING, CLAUDIA CARVER, CAROL A. STALKER, RICHARD FRY, and BETSY SCHAEFER
Thirty-three couples with severe marital discord referred to a psychiatric outpatient department were randomly assigned to Cognitive Marital Therapy or a control group. Cognitive Marital Therapy is a brief, structured couple therapy, which involves spouses in reciprocal sevdisclosure of personal constructs. The control group received the same number of sessions of self-disclosure from a programmed marital enhancement text. Personal distress, marital adjustment, marital quality, and aspects of self-disclosure were measured before and afer treatment. Symptoms of depression as well as somatic and compulsive complaints showed significant improvement in both groups. The wives exhibited a trend suggesting that they were making more self- disclosures to their spouses afier counseling. No discernable differences in outcome were found between the marital therapy group and the control group. Marital intimacy and marital satisfaction did not improve significantly over the course of 10 therapy sessions. This study suggests that the role of seydisclosure in marital therapy needs further clarification. Jourard defined self-disclosure as the process of verbally revealing one’s feelings, thoughts, and needs to another person.’ Spouses who report more self-disclosure in their marriage tend to report greater marital satisfaction.2 Couples with marital discord report reduced amounts of self-disclosures, which are not affectively c ~ n g r u e n t . ” One ~ might assume that a technique that increases the amount of self-disclosures between spouses, insures the reciprocity of these disclosures, and attempts to facilitate self-disclosures that are affectively congruent might be effective in reducing marital discord. Cognitive Marital Therapy (CMT) is Edward M. Waring, MD, is Chairman of Psychiatry and Professor, Queens University. Claudia Carver, MSW, CSW, and Carol A. Stalker, MSW, CSW. are both Social Workers, Department of Psychiatry, University Hospital. Richard Fry, BA, and Betsy Schaefer, BA, are both Research Assistants, Department of Psychiatry, University Hospital. Address reprint requests to: Dr. E. M. Waring, Hotel Dieu, 166 Brock Street, Kingston, Ontario, N7L 5G2, Canada.
Journal of Sex & Marital Therapy, Vol. 16, No. 3, Fall 1990 0 BrunnedMazel, Inc. 165
Downloaded by [University of South Florida] at 13:44 09 October 2014
a standardized, structured, brief marital therapy designed to enhance marital intimacy through facilitating cognitive self-dis~losure.(~.~ Cognitive Marital Therapy was developed from Kelly’s theory of personal constructs.8 Neimeyer!’ l o has written about a personal construct approach to marital counseling and suggests that spouses choose those alternatives that appear to offer the greatest opportunity to extend and define personal understandings of experience. Kellys observed, “A man will choose to marry if that appears to provide him with the opportunity to enlarge or secure his anticipatory system” (p. 523). Waring“ suggests this “anticipatory system” develops largely from the observation and experience with one’s parents’ level of marital intimacy. SegravesI2 has developed Kelly’s model for the treatment of marital discord suggesting: 1 ) faulty cognitive schemata of members of the opposite sex are of primary importance in the genesis and maintenance of marital discord; 2) spouses tend to behave toward one another in such a way as to invite behaviors that are congruent with personal constructs; and 3) maladaptive interactional patterns maintain individual psychopathology in spouses. Controlled outcome trials o f marital therapy in psychiatric clinical settings involving patients o r couples have been rare. Friedman’s13study of the combination of marital therapy and antidepressants in depressed outpatients and Crowe’s’Jresearch with neurotic outpatients are the only two to the best of our knowledge. Two controlled outcome trials of Cognitive Marital Therapy in combination with antidepressants in hospitalized women with major affective disorder and outpatient women Lvith dysthyrnia have been reported.’”‘“T h e present study evaluates the effectiveness of Cognitive Marital Therapy (CMT) in couples with severe marital discord attending a psychiatric outpatient clinic.
Hypotheses Specific hypotheses concerning the effects of Cognitive Marital Therapy (CMT) on the marital relationship and on presenting symptoms are as follows: 1 ) Compared to a control treatment group, CMT will result in greater improvement of marital functioning after 10 sessions. This would be evidenced by reduced scores on the Marital Satisfaction Inventory (MSI) scales originally defined as problematic and, thus, a more “normal” MSI profile at the posttherapy assessment. 2) Compared to the control group, CMT will result in improved marital intimacy. Specifically, subscales of the Waring Intimacy Questionnaire (WQ) and WIQ Total Intimacy scores should exhibit greater improvement after 10 weeks. 3) Compared to the control group, CMT will result in increased selfdisclosure after a 10-week period. Greater increases should be found o n the Self-Disclosure Questionnaire. After 10 weeks, the CMT group can be expected to demonstrate larger increases in scores on the SelfDisclosure inventory than will the control group.
A Randomized Clinical Trial of Cognitive Marilal Therapy
167
4) CMT will show an improvement over the control group in symptom reduction over 10 weeks. General Health Questionnaire (GHQ) and Symptom Check List (SCL-90) scores will show more decline in the active treatment group.
METHOD
Downloaded by [University of South Florida] at 13:44 09 October 2014
T h e research design stipulated the following inclusion criteria for each couple:
1 ) T h e presenting problem was marital discord, consisting of frequent arguments, or conflicts over differences of opinion. 2) Spouses were to have been in a stable marriage, either living together, or recently separated from a marriage of at least 5 years. 3) One o r both spouses may have had a score greater than 4 on the General Health Questionnaire, but no evidence of major psychiatric disorder. 4) A t least one of the spouses’ Total Intimacy scores on the W I Q would be below 22, with two of three scores on Affection, Conflict Resolution, and Compatibility being the lowest. Couples satisfying the inclusion and exclusion criteria were randomly assigned either to 10 sessions of CMT o r to 10 sessions of a control treatment, which will be described. Thirty-three couples were included in the study, and all of them were expected to read one chapter per week from the marital education manual, Time for a Better M a r r z ~ g e . ’ ~ Treatments
Cognitive Marital Therapy. CMT is a structured, time-limited intervention. It can be summarized and specified by the instructions to therapists to comply with the following nine things to do: 1) Explain the sessions and treatment contract to couples. 2) Initiate each session with the question “What were you thinking while your spouse was talking?” or the last question from the previous session. 3) Facilitate self-disclosure of personal constructs. Spouses are asked to disclose, individually to the therapist, their theories as to why they are not close as a couple. Each is asked to speak in turn, comment upon each other’s disclosures, and to give additional information when necessary. 4) Clarify any ambiguous disclosures made by either spouse during a session. 5 ) Redirect the attention of spouses to the discussion at hand, when warranted, or to personal constructs they have previously disclosed, when appropriate.
168
J o u n i d of Spx &f Marital Therapy, V d 1 6 , N o . 3 , Fall 1990
6) Ask nondirective questions to encourage the disclosure of personal constructs. 7) Encourage the exploration of the parents’ marriage. 8) Extend this exploration to the marriages of grandparents, friends, and other couples. 9) I n later sessions, present the therapist’s theories as to why the couple a r e not close, as material for discussion.
Downloaded by [University of South Florida] at 13:44 09 October 2014
Also, the CMT protocol includes the following five things not to do: 1 ) Do not allow outbursts of emotion to interfere with the discussion process. Instead, coach and model good listening skills. 2) Do not allow assumptions tantamount to “mind reading” between spouses, but redirect such material to its conscious, cognitive components. 3 ) Do riot confront or identify nonverbal behaviors of spouses, unless they disrupt the treatment contract. 3 ) Do riot allow the spouses to interrupt each other’s disclosures during sessions. 5) Do not interpret resistances. Terminate sessions if couples will n o longer mutually self-disclose or attend sessions. Cognitive Marital Therapy is presented in 10 hour-long, weekly session?. A therapist manual is available for the training of therapists in Cognitive Marital Therapy to ensure a structured, standardized approach. Audiotapes of sessions were supervised to ensure standardization of therapy.
Control Therapy. Waiting-list control subjects rarely improve without In the experience of Fiske et al.‘O a n d the authors, waiting-list subjects pose significant threats to research designs in terms of dropouts, couples separating, and the seeking of help elsewhere. Instead of a waiting-list, w e used a control therapy group in which a marital, interpersonal-skills training manual, Timefor a Better Marrzage, was given to the couples. They were expected to read one chapter per week a n d self-disclose their thoughts about the chapters with a research assistant in 10 hour-long, weekly sessions. Control marital counseling was a n ad hoc, couple-directed intervention. T h e material in the book covers stand a r d communication skills, mutual encouragement, establishment of objectives, a n d behaviors to practice. T h e research assistant modeled listening skills, a n d directed couples to focus o n passages that referred to problems they experienced, and to recognize those areas in which they were free of conflict. When couples claimed that the material was not applicable to them o r digressed into domestic conflicts, the research assistant showed them where concepts in the book were more cogent than they had realized. Couples understood that they could enter C M T after 10 sessions of control marital counseling. T h e major differences between CMT and control counseling were that CMT therapists were trained in marital counseling, while the research
A Randomized Clinical Trial of Cognitive Marital Therapy
169
assistants had no formal training in the area; CMT has an inherent structure to its sessions, but control counseling was client-centered and structured only by the material in the book; and CMT requires spouses to explore their personal constructs regarding their attitudes and expectations, while control therapy was oriented toward encouraging couples to have faith in their own ability to resolve their problems. However, all couples read the same text and were involved in sessions promoting selfdisclosure.
Downloaded by [University of South Florida] at 13:44 09 October 2014
Data Collection Procedure Immediately after the initial assessment interview, couples completed a number of self-report inventories described below and a demographic information questionnaire. They then began the therapy sessions: 10 weeks of CMT or the control treatment. After 10 weeks, the measures were repeated with the exception of the demographic form and the personality questionnaire (to be described). In addition to these assessments, audiotapes were made of some sessions to monitor patient and therapist compliance with the study protocol. Differential dropout rates between the CMT and control groups were examined. At the end of 10 weeks, the couples in the control group were offered Cognitive Marital Therapy. Statistical Analyses T h e hypotheses described above were tested using repeated measures analyses of variance, with treatment condition as a between-groups factor. Each of the psychological constructs (i.e., marital functioning, marital intimacy, self-disclosure, and symptomatology) were measured by several scales or subscales. Each of these were analyzed separately, but interpreted within their overall constructs, and with respect to results that may be d u e to chance. Pretherapy levels of the constructs measured were tested between treatment groups to assess the effectiveness of the random assignment process, as suggested by Bancroft, Dickerson, Fairburn, Gray, Greenwood, Stevenson and Warner.*’ Groups of subscales identified as the most likely to have an effect on therapy outcome were entered into multivariate analyses of variance, with therapy type used as the treatment factor. Dropout rates were examined as an outcome d u e to therapy type via a Chi-squared analysis of cross-tabulated categorizations. T h e effects of pretherapy levels on outcome measures of personality traits and demographic characteristics on dropout status were analyzed with multivariate analyses of variance in subsets of related measures. Measures Measures were chosen to assess three theoretical constructs: the marital relationship, the presenting complaint or symptomatology, and person-
ality and demographic characteristics that may moderate responses to psychotherapy. Symptoms of psychiatric illness were monitored, since they have been shown to be associated with marital
Downloaded by [University of South Florida] at 13:44 09 October 2014
Marital Relalionships Iwtrzi?nent.s
Ma?-ital Satisfaction Inventory. T h e MSI is a self-report measure that identifies the nature and extent of marital distress along several dimensions.')>I t consists of 280 true-or-false items on 1 1 scales. N o total score is produced, but one of the scales offers a measure of overall marital discontent . T h e 1 1 scales are as follows: Conventionalization (CNV), the tendency to distort the appraisal of the marriage in a socially desirable direction; Global Distress (GDS), overall dissatisfaction, along the dimensions of general unhappiness with the marriage, and uncertain commitment to the marriage; Affective Communication (AFC), dissatisfaction with the amount of affection and understanding expressed by the spouse, referring t o inadequate affection anc! caring, lack of ern pathy a n d understanding, and failure of the spouse to self-disclose; Problem-Solving Comniunication (PSC), the couple's general ineffectiveness in resolving differences; Time Together (TTO), reflecting lack of common interests a n d dissatisfaction with the quality and quantity of leisure time together; Disagreement About Finances ( F I N ) , discord regarding the management of family finances; Sexual Dissatisfaction (SEX), dissatisfaction with the frequency and quality of sexual activities; Role Orientation (ROR), reflecting adoption of a traditional versus nontraditional orientation toward marital and parental sex roles; Family History of Distress (FAM), reflecting a n unhappy childhood and disharmony in the marriages of respondent's parents 'and extended family; Dissatisfaction With Children (DSC), dissatisfaction or disappointment with children, reflecting parent-child rather than between-spouse relationships; and finally, Conflict Over Childrearing (CCR), the extent of conflict between the spouses regarding childrearing practices. Except for C N V a n d ROR, all scales are scored in the direction of discontent so high scores indicate high levels of dissatisfaction within t h e specific area. T h e number of items differs for each scale a n d maximum raw scores can range from 15 on FAM t o 43 o n GDS.
Waring Inlzmacy Questionnuire. The WIQ is a 90-item true-or-false questionnaire specifically developed to measure the quality a n d quantity of marital intimacy.'6 T h e W I Q was developed from the theory that t h e quality of intimacy between the spouses is the major determinant of marital adjustment, and the quantity of intimacy is negatively correlated with the presence and severity of nonpsychotic emotional illness in one or both of the spouses. T h e W I Q measures eight facets of marital intimacy: Conflict Resolution (CR), the ease with which differences of opinion are resolved; Affection (AFF), the degree to which feelings of emotional closeness a r e expressed
Downloaded by [University of South Florida] at 13:44 09 October 2014
A Rundomized Clinical Trial of Co
